PAUL  B.HOEBER 

MEDICAL  BOOKS 

69E.  59thSt.,N.Y.| 


UtUnntt  Htbrarg 


GUIDING    PRINCIPLES 

IN 

SURGICAL  PRACTICE 


BY 
FREDERICK-EMIL  NEEF,  B.S.,  M.L.,  M.  D. 

NEW  YORK  CITY 


SURGERY    PUBWSHING    COMPANY 

92   WILI^IAM    STREET 

NEW   YORK 

1914 


Copyright,  June,  1914 

By 

SURGERY    PUBLISHING    COMPANY 

New  York 


If  3133 


PREFACE. 

In  offering  this  monograph  which  embodies  some 
of  the  guiding  principles  in  surgical  practice,  I  real- 
ize that  it  expresses  only  an  individual  viewpoint. 
To  have  reflected  on  a  safe  and  logical  working 
method,  is  a  vital  prerequisite  in  surgical  training. 
If,  in  any  case,  this  outline,  which  is  derived  chiefly 
from  clinical  study,  has  helped  to  supply  a  system 
where  there  was  none,  the  tedious  task  of  formu- 
lating it  will  have  been  worth  while. 

Frederick-Emil  Neef. 
300  Central  Park  West, 
New  York  City. 


Digitized,  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/guidingprincipleOOneef 


CONTENTS. 

I.     General  Considerations 1 

II.  Preparation  of  the  Patient  for  Operation  5 

III.  Sterile  Wash  and  Wound  Dressing's.  .  .  14 

IV.  Sterilization    of    Utensils    and    Instru- 

ments for  Operation 27 

V,     The  Surgeon's  Hands 36 

VI.  Wound-Healing  and  Scar  Formation.  . .  45 

VII.  Aseptic  Suture  Material 59 

VIII.     The  Anesthesia 74 

IX.     The  Incision 87 

X.     The  Course  of  the  Operation 100 

XL     Care  of  the  Patient  After  Operation .. .  110 

XII.     The  Interpretation   of   Post-Operative 

Fever  in  Aseptic  Cases 133 

XIII.  The  Treatment  of  Unclean  Wounds  ...  154 

XIV.  Conclusion 167 


CHAPTER  I 

General  Considerations 

Good  surgical  judgment,  logical  asepsis,  dex- 
terous technic  are  three  requirements  that  are  of 
principal  importance  in  the  practice  of  surgery. 
But,  while  surgical  judgment  must  gradually  ma-  Surgical 
ture,  it  can  be  supplied,  to  some  extent,  by  the  care- 
ful study  of  one's  work,  and,  by  consulting  with 
others  of  greater  experience.  Dexterity  in  execut-  Dexterous 
ing  an  operation  can  only  come  with  frequent  Technic 
repetition  of  a  definite  technic.  It  will  be  acquired 
sooner  by  him  whom  the  hospital  entrusts  with  the 
surgical  care  of  its  numerous  poor,  than  by  the  col- 
league who  has  to  rely  on  his  private  practice  alone 
for  a  repetition  of  similar  cases.  Finally,  the 
preservation  of  a  logical  asepsis  throughout  the  ^°sica 
course  of  an  operation  involves  the  surgeon's  at- 
tention and  solicitude  in  many  directions.  Wound 
contamination  may  be  traceable  to  faulty  or  defi- 
cient local  preparation  of  the  territory  for  opera- 
tion, or  to  the  hands  of  the  operator,  or  to  one  of 
his  assistants  or  nurses,  or  to  the  instruments  he 
uses,  or  the  suture  material ;  it  may  be  an  operating- 
room  basin  or  utensil  that  is  not  surgically  clean; 
or  gauze  or  wound-dressings  or  contact  with  un- 
sterile  wash;  or,  most  important  of  all,  injudicious 
handling  of  a  bacterial  nidus  existing  in  the  living 
structures  which  come  within  the  compass  -of  the 
operation.  While  acting  in  the  interest  of  his 
patient's  future  physical  well-being,  the  surgeon  as- 

(1) 


2      Guiding  Principles  in  Surgical  Practice 


Extrinsic 

and  Intrinsic 

Infection 


sumes  all  the  responsibility  for  the  outcome  of  his 
measures,  and  for  any  violation  of  asepsis  by  those 
delegated  to  assist  him.  No  matter  therefore,  how 
exacting  he  may  be  during  the  tension  of  his  work, 
he  is  always  entitled  to  alert  and  faithful  coopera- 
tion. 

There  would  be  little  difference  between  the  sur- 
geon and  the  assassin,  if  the  wound  were  not  in- 
flicted in  the  hope  of  bettering  the  patient's  physical 
condition.  No  operation  which  is  not  urgent, 
should  be  undertaken  before  the  safety  of  the  sur- 
gical measure  has  been  duly  weighed.  Most  cases 
of  post-operative  death  are  due  to  infection.  The 
sources  of  danger  in  operating  are  two-fold,  extrin- 
sic and  intrinsic.  With  the  strict  present  day 
regime,  in  the  preparation  of  the  patient,  Jtnd  in  the 
operating-room  service,  infection  which  is  due  to 
extrinsic  causes  has  become  systematically  avoid- 
able. Most  major  complications  and  deaths  which  oc- 
cur after  operation  are  due  to  infection  which  is  in- 
trinsic in  origin.  The  difficulty  arises  out  of  the  fact 
that  it  is  hard  to  deal  with  infected  structures,  with- 
out disseminating  infection.  Bacterial  foci  may  be 
normally  present  within  the  body;  thus  in  the  ali- 
mentary canal  or  the  genito-urinary  tract.  Althoug<h 
aseptic  in  the  new-born,  pathogenic  bacteria  very 
soon  gain  access  to  the  bowel;  and,  at  a  later  date, 
with  the  advent  of  sexual  maturity,  the  genito- 
urinary tract  is  prone  to  lose  its  relatively  aseptic 
character.  Any  technic  which  involves  the  opening 
of  these  hollow  organs  during  the  course  of  an  op- 
eration, is  at  6nce  fraught  with  additional  risks.  In 
a  strictly  aseptic  case,  that  is  one  in  which  the  tem- 
perature is  absolutely  normal  before  operation, 
these  are  among  the  chief  avenues  of  danger  from 


Guiding  Principles  in  Surgical  Practice        3 

intrinsic  infection.  But  when  the  case  is  primarily 
not  an  aseptic  one,  as  indicated  by  the  preoperative 
temperaturCj  then  the  problem  becomes  encumbered 
by  the  presence  of  a  bacterial  herd  at  the  site  of 
disease  and  perhaps  permeating  the  very  structures 
which  are  involved  in  the  operation.  Because  the 
outskirts  of  disease  about  an  infected  focus  are  not 
always  plainly  demarcated,  the  surgeon's  instru- 
ments and  hands  become  contaminated  while  divid- 
ing tissues  which  he  assumes  to  be  sterile.  Besides 
the  risk  of  transplanting  germ-life  from  one  struc- 
ture to  another,  if  the  lymph  stasis  or  hemostasis 
is  not  perfect  and  efifiicient  drainage  is  not  employed, 
the  accumulating  fluid  may  prove  to  be  a  fertile 
culture  medium  for  the  remaining  bacteria  and  lead 
to  peritonitis  or  sepsis.  Experience  has  taught  that 
hysterectomy  for  cancer  of  the  cervix  cannot  be 
safely  undertaken  without  drainage.  The  cancer- 
ous area  is  nearly  always  invaded  by  a  varied  bac- 
terial flora  and  the  paracervical  and  parametrial 
cellular  tissues  are  not  often  clean. 

While  the  presence  of  preoperative  fever  indi-  Preoperative 
cates  that  the  case  is  not  a  strictly  aseptic  one,  it  Fever 
must  be  borne  in  mind  that  the  absence  of  a  tem- 
perature rise  just  before  operation  is  not  always 
equally  significant.  Indeed,  in  the  course  of  a 
thrombo-phlebitis,  there  may  be  afebrile  intervals 
of  shorter  or  longer  duration;  a  few  days'  record 
of  preoperative  temperature  may  be  misleading,  and 
operation  performed  under  the  impression  that  the 
case  is  a  clean  one,  may  be  attended  by  post-opera- 
tive embolism.  Endocarditis  may  be  similarly-  latent 
and  afebrile  for  short  periods,  although  even  slight 
perturbations  should  arouse  suspicion  and  an  ex- 
amination of  the  blood  may  at  once  reveal  an  over- 


4      Guiding  Principles  in  Surgical  Practice 

whelming  leucocytosis  and  high  polymorphnuclear 
cell  percentage. 
Working  From  this  brief  consideration  can  be  gleaned  two 
Rules  valuable  working  rules.  Firstly,  never  to  urge  an 
operation  which  can  be  circumvented  and  is  not 
imperative,  when  the  patient  has  not  an  absolutely 
normal  temperature  before  operation.  Secondly, 
when  several  methods  of  operating  come  in  ques- 
tion, to  give  preference  to  those  in  which  intrinsic 
infection  of  the  wound  is  least  likely  to  occur. 


CHAPTER  II 

Preparation  of  the  Patient  for  Operation 

The  patient,  properly  prepared  for  operation  un- 
der general  anesthesia,  should,  as  a  rule,  have  no 
digesting  food  in  the  stomach,  and  the  large  bowel 
should  be  emptied;  but  this  does  not  mean  that  she  Qgneral 
should  be  translated  into  a  state  of  hunger.  A  and  Local 
starving  patient  is  more  likely  to  suffer  ill-effects  Preparation 
from  the  anesthetic,  and  recovery  from  the  opera- 
tion itself  is  less  assured.  Finally,  the  field  of  op- 
eration is  to  be  rendered  surgically  clean,  in  order 
to  exclude  the  introduction  of  pathogenic  organisms 
from  without  into  the  wound  which  the  surgeon  in- 
flicts— extraneous  or  extrinsic  infection.  This  is 
done  in  the  primarily  aseptic  case  as  well  as  that 
which  is  not.  The  problem  resolves  itself  into  the 
consideration  of  the  sterilization  of  the  skin,  and 
the  sterilization  of  the  mucous  membrane.  In  a 
general  way,  the  procedures  followed  in  making  the 
skin  surgically  clean  for  operation,  may  be  grouped 
under  two  headings:  those  which  depend  on  me- 
chanical cleansing,  and  those  which  are  based  on 
chemical  disinfection.  Although  with  the  exercise  disinfection 
of  due  precaution,  both  procedures  have  yielded 
good  results,  both  nevertheless  present  inadequacies 
which  should  not  be  overlooked  in  the  search  for 
methods  which  are  simple  in  their  application  and, 
at  the  same  time,  uniformly  reliable. 

There  is  the  well  founded  objection  to  the.  usual 
mechanical  cleansing  methods,  that  besides  being 
time-consuming,   the   microscopic    recesses   of    the 

(5) 


6      Guiding  Principles  in  Surgical  Practice 

skin   cannot  become   thoroughly  accessible   to  the 
crude  scrubbing  manoeuvres.     On  the  other  hand, 
jec  ions  ^YiQ  disinfecting  methods  which  are  commonly  em- 
to  these     ,        ,    j.       •  i  i-,  ..•^, 

Methods  P^oy^d,  tor  mstance,  those  which  consist  in  apply- 
ing two  coats  of  tincture  of  iodine  to  the  skin,  one 
before,  and  one  at  the  time  of  operation,  provide 
no  satisfactory  safeguard  against  intermediary  con- 
tamination of  the  operating  field.  In  other  words, 
the  final  coat  of  iodine  is  allowed  only  few  minutes 
time  during  which  to  exert  its  disinfectant  action 
before  the  operation  begins.  Can  this  mean  trust- 
worthy sterilization  when  the  field  has  been  re- 
cently soiled? 

Notwithstanding  these  and  other  objections,  both 
methods  have  proven  to  be  comparatively  safe  when 
carried  out  under  the  strict  present  day  hospital 
regime,  at  least  as  far  as  the  more  serious  conse- 
quences of  an  insufficient  surface  asepsis  are 
concerned.  But  in  these  conclusions,  minor  per- 
turbations in  the  aseptic  rise  due  to  a  slight  stitch 
involvement,  or  delayed  infections,  have  been  large- 
ly disregarded.  Moreover,  almost  any  method  of 
preparation  will  appear  to  be  satisfactory  where  the 
field  of  operation  was  not  seriously  contaminated 
with  bacteria,  above  all  with  spore-forms.  It  is 
with  a  view  of  eliminating  some  of  the  weak  points 
of  the  mechanical  cleansing  and  chemical  disinfect- 
Combined  '^^^  methods,  that  these  have  been  variously  com- 
Methods  bined — combined  methods.  In  such  a  combined 
method,  the  disinfectant  can  be  applied  early  to  give 
it  sufficient  time  to  act,  while  the  cleansing  measures 
immediately  precede  the  operation. 

In  one  of  these  methods  tincture  of  iodine 
(33^%)  is  applied  to  the  dry  skin  over  night,  and 
followed  by  the  soap-suds — sterile  water — alcohol 


Guiding  Principles  in  Surgical  Practice        7 

sequence  before  operation.  This  represents  a  safe 
routine  when  conscientiously  carried  out;  perhaps 
better,  in  the  long  run,  than  either  the  method  by 
mechanical  cleansing  with  soap  and  water  or  that 
by  disinfection  alone.  But  the  proper  execution  of 
the  many  fluid  rounds  of  the  old  soap  and  water 
sequence  demands  more  alertness  than  it  often  re- 
ceives from  the  assistant  to  whom  it  is  entrusted. 
The  question  therefore  naturally  arises  if  the  soap 
and  water  cannot  be  altogether  dispensed  with,  and 
supplanted  by  a  single  cleansing  solution. 

The  following  formulae  and  procedure  represent 
the  net  result  of  my  efforts  since  1908  to  develop 
such  a  combined  method  which  is  comparatively 
simple  and  safe.  In  its  application  two  solutions 
are  necessary: 

Liquor  Disinfectans — Solution  No.  1. 

Rp.     Iodine  crystals,  3.5. 
Alcohol  U.  S.  P. 
Carbon  tetrachloride, 
aa  ad.  100.0. 

D.     Keep  in  a  dark  glass-stoppered  bottle. 
S.     Disinfecting  solution  for  the  skin. 

Liquor  Expurgans — Solution  No.  2. 

Rp.     Methyl  Salicylate,  1.0. 
Carbon  tetrachloride. 
Alcohol  U.  S.  P. 
aa  ad.  100.0 

D.  S.     Cleansing  solution  for  the  skin. 

On  the  day  before  operation,  unless  contraindi- 
cated,  the  patients  receive  a  cleansing  bath  with 
soap  and  warm  water.     This  removes  the  desqua- 


8      Guiding  Principles  in  Surgical  Practice 

mating  surface  epithelium  and  exposes  a  cleaner 
substratum.  The  area  for  operation  is  then  shaved, 
washed  free  of  all  traces  of  soap,  well  dried  with 
a  sterile  towel  and  protected  with  a  cover  of  sterile 
gauze.  On  the  evening  before  operation  the  nurse 
swabs  the  surface  with  Liquor  Disinfectans — Solu- 
tion No.  1 — in  sufficient  quantity  to  produce  a  deep 
brownish-yellow  stain.  Hairy  or  sebaceous  areas, 
creases  and  folds  in  the  skin,  and  the  umbilicus  re- 
quire particular  attention.  Sterile  gauze  protects 
the  surface  and  is  securely  held  in  place  by  zinc 
oxide  adhesive  strips. 

In  the  operating-room  a  single  washing  of  the 
abdomen  with  Liquor  Expurgans — Solution  No.  2 
— and  drying  of  it  with  a  sterile  towel  is  all  that  pre- 
cedes the  incision. 

In  this  routine  the  patient's  cleansing  bath  first 
removes  the  altered,  acid  sweat  with  admixed  fatty 
acids — formic,  acetic,  propionic,  butyric,  caproic, 
capric — which  stagnate  upon  the  surface  of  the 
Principles  gj^jn ;  and  allows  it  to  be  replaced  by  a  fresh,  more 
Involved.  ^^  less  alkaline  secretion  from  the  sudoriparous 
glands.  There  is  an  interval  after  the  bath,  so  that 
the  skin  has  time  to  become  dry  by  evaporation  be- 
fore the  disinfecting  solution  is  used.  The  com- 
patibility of  the  disinfectant  with  the  heterogeneous 
secretion  of  the  skin  is  increased,  by  modifying  the 
alcoholic  menstruum  in  which  it  is  dissolved,  with 
an  equal  part  of  the  fat-solvent  carbon  tetrachloride. 

The  pure  tincture  of  iodine  which  consists  only  of 
iodine  crystals  dissolved  in  95%  alcohol,  such  as 
the  Tinctura  lodi,  U.  S.  P.,  1890,  is  relatively  in- 
compatible with  water.  Traces  of  moisture,  how- 
ever, can  be  attracted  by  the  alcohol  without  throw- 
ing the  iodine  out  of  solution.    If  potassium  iodide 


Guiding  Principles  in  Surgical  Practice        9 


is  added,  the  iodine  becomes  at  once  freely  water- 
soluble.  This  is  the  principle  on  which  Lugol's 
iodine  solution,  Liquor  lodi  Compositus,  U.  S.  P., 
is  based.  When  iodine  gains  entrance  to  a  sweat 
gland,  it  is  probably  attracted  by  the  alkalinity  of 
the  secretion  from  the  deeper  recesses  of  the  gland 
and  in  small  part,  converted  into  water-soluble 
iodide — thus  it  might  be  said  that  the  duct  of  the 
sweat  gland  represents  a  miniature  test-tube  in 
which  minute  quantities  of  Lugol's  solution  are 
formed. 

In  considering  skin  disinfection  it  is  in  point  to 
regard  the  sweat  which  is  supplied  by  the  sudori- 
parous glands,  as  distinctly  fatty,  and  not  as  purely 
aqueous.  Moreover,  the  function  of  supplying  the 
fatty  secretion  of  the  skin  does  not  seem  to  be 
restricted  solely  to  the  sebaceous  glands ;  thus, 
neutral  fats — ^palmitin  and  stearin — ^have  been 
found  in  the  sweat  of  the  palm  of  the  hand  where 
no  sebaceous  glands  exist,  as  well  as  in  the  perspira- 
tion generally.  In  addition  the  elaboration  of  fatty 
bodies  has  been  demonstrated  to  take  place  in  small 
part,  hand  in  hand  with  keratin-formation,  in  the 
epithelial  cells  of  the  cornifying  layers  of  the  epi- 
dermis itself.  Sweat  may  therefore  be  correctly 
classed  as  a  fatty  secretion.  But  an  aqueous  solu- 
tion such  as  Lugol's  Iodine  would  be  incompatible 
with  fatty  bodies.  On  the  other  hand,  the  pure 
tincture  fails  in  penetrating  power  because  alcohol 
is  not  a  fat-solvent.  For  this  reason,  when  iodine 
is  not  employed  in  a  fat-solvent  vehicle,  particular 
stress  has  to  be  laid  on  the  removal  of  the  inspis- 
sated fatty  secretion  from  the  skin  beforehand. 
Especially  is  this  true,  where  the  abdominal  inci- 
sion encroaches  upon  the  hairy  zone  of  the  pubes. 


Fatty 
Nature  of 
Sweat 


10      Guiding  Principles  in  Surgical  Practice 


Cleansing 

Instead    of 

Disinfection? 


Emergency 
Preparation 


If,  however,  the  disinfectant  solution  is  of  itself 
capable  of  penetrating  fatty  bodies  as  in  the  for- 
mula of  the  method  which  has  been  outlined,  such 
a  preparatory  step  becomes  unnecessary. 

Finally,  instead  of  repeating  the  disinfection  of 
the  field  in  the  operating  room  where  even  the  most 
powerful  agent  is  scarcely  given  time  to  exert  its 
full  germicidal  action  recourse  is  had  to  a  simplified 
cleansing  method  instead.  This  procedure  may  not 
appeal  to  those  who  endorse  the  radical  iodine 
method,  but  for  my  own  part,  I  am  inclined  to  base 
more  reliance  on  operating-room  methods  which 
have  in  view  the  removal  of  bacteria  by  mechanical 
cleansing,  than  on  those  which  aim  to  destroy  them 
by  a  single  disinfection  immediately  before  opera- 
tion. However,  no  cleansing  solution,  whatever  its 
chemical  nature,  can  substitute  soap  and  water  and 
at  the  same  time  make  the  act  of  cleansing  itself 
redundant. 

In  emergency  cases,  it  is  not  infrequently  neces- 
sary to  perform  an  operation  on  short  notice,  and 
sometimes  the  only  preparation  the  patient  can 
receive  has  to  be  given  in  the  operating  room 
before  operation.  There  may  have  been  no  pre- 
liminary cleansing  bath  to  aid  in  making  the 
territory  germless.  In  such  cases,  naturally,  com- 
bined methods  are  not  applicable.  The  question 
arises  what  should,  in  such  event,  be  the  prepara- 
tion of  election.  The  advocate  of  the  radical  iodine 
method  who  is  satisfied  with  a  single  application  of 
the  disinfectant,  previous  to  operation,  is  not  re- 
quired to  modify  his  plan  of  procedure  in  an  emerg- 
ency case.  A  single  coat  of  the  full  or  half  strength 
tincture  of  iodine  is  applied  to  the  skin  of  the  abdo- 
men, or  to  the  resistant  vaginal  mucous  membrane 


Guiding  Principles  in  Surgical  Practice      11 


with  equal  readiness.  But  those  who  have  some 
scruple  as  to  the  reliability  of  such  disinfectant 
methods  for  routine  work,  will  have  to  resort  to 
one  of  the  mechanical  cleansing  methods.  There  is 
the  more  complicated  soap  and  water  sequence  of 
the  older  school ;  also  the  newer  method  of  simple 
cleansing  with  a  piece  of  soft  soap  and  warm  sterile 
water  without  any  further  embellishment.  The 
effectiveness  of  this  simple  method  in  obtaining 
surgical  cleanliness  is  not  confined  to  the  skin  but 
extends,  as  well,  to  the  mucous  membrane.  Lastly, 
warm,  aqueous  lysol  1-1000,  combining  antiseptic 
potency  with  the  properties  of  a  soap  solution,  is 
a  very  useful  substitute,  especially  in  the  gynecolog- 
ical or  obstetrical  emergency  operation. 

Because  of  the  greater  vulnerability  of  the  mu- 
cous membranes,  and  the  different  character  of 
their  physiological  secretions,  methods  suitable  for 
the  preparation  of  the  .skin  need  not  necessarily 
be  adequate  for  them.  Disinfection  with  tinc- 
ture of  iodine,  or  cleansing  with  aqueous  lysol, 
may  be  feasible  in  the  case  of  the  vagina  of 
the  multiparous  patient,  but  it  cannot  be  used  in  the 
cavity  of  the  nose  and  mouth  or  in  the  bladder  or 
rectum.  The  diseased,  catarrhal  mucous  mem- 
branes may  be  bathed  with  an  aqueous  solution  of 
tannic  acid  for  varying  periods  before  the  opera- 
tion is  undertaken.  Tannic  acid  precipitates  the 
chief  constituent  of  the  mucus  in  the  form  of  an  in- 
soluble tanno-proteid,  and  with  it,  the  entangled 
bacteria;  the  deposited  mucus  is  then  readily 
washed  away.  A  1  %  solution  of  the  acid  in  water 
is  sufficient  for  ordinary  purposes.  But  even  a  50% 
aqueous  solution  can  be  employed  without  injury 
or  toxic  effect.    Because  it  is  neither  poisonous  nor 


Preparation  of 
the  Mucous 
Membrane 


12       Guiding  Principles  in  Surgical  Practice 

, caustic,  an  aqueous  solution  of  tannic  acid  can  be 
used  in  the  naso-pharynx,  mouth,  stomach,  bowel, 
bladder,  vagina,  in  the  form  of  irrigations,  in  pre- 
paring a  patient  for  operation.  When  prescribed 
as  a  vaginal  douche  for  regular  use,  it  is  well  to 
know  that  the  fluid  is  apt  to  produce  a  bluish  stain 
in  linen  with  which  it  may  come  in  contact.  Metal 
instruments  are  not  affected  by  it  in  an  appreciable 
manner,  so  that  it  can  be  employed  in  the  operating 
room  as  well  as  at  the  bedside. 

nurse's  outline  of  preparations  for  abdominal 
and  vaginal  operation. 

Rectal  temperatures  before  operation. 

Urine  analysis  before  operation. 
Nurses' 
Outline  of      10  A.  M.     Calomel,  gr.  iij  given  in  a  single  dose. 
Preparations  Unless  contraindicated   allow   the  pa- 

tient to  have  a  general  bath. 
Shave  the  abdomen,  pubes,  vulva,  in- 
side of  thighs;  pubes  closely. 
Render  the   area   clean  by  m^eans   of 
soap-suds  and  water,  the  umbilicus 
and  pubes  receiving  particular  atten- 
tion. 
Protect   the    abdomen    with    a    sterile 
towel  or  gauze  dressing. 

12  A.  M.     Dinner.     Selected  diet. 

4  P.  M.     Effervescent  Magnesium  Citrate,  U.  S. 

P.,  3ij. 
Soap-suds  enema  until  clear. 
Vaginal  douche,   1-1000  lysol,   1-1000 

Lugol's  iodine  or  1-100  tannic  acid 

solution,  Cij. 


Guiding  Principles  in  Surgical  Practice      13 


6  P.  M.     Supper.    Selected  diet. 

8  P.  M.     Soap-suds  enema  until  clear. 

Vaginal  douche,  1-1000  lysol,   1-1000 

Lugol's  iodine  or  1-100  tannic  acid 

solution,  Cij. 

Apply  a  good  coat  of  tincture  of  iodine 

or  else  Solution  No.  1  to  the  abdomen 

and  cover  with  a  sterile  dressing. 

4  A.  M.     The  patient  receives  some  non-curdling 
drink  if  she  is  awake. 

7.30  A.  M.  Morphine    sulphate   gr.    %    subcutane- 
ously. 
Allow  the  patient  to  empty  her  bladder. 

8  A.  M.     Ready  for  operation. 

In  the  operating  room  the  sterile  dressing  is  re- 
moved and  the  abdomen  is  cleansed  systematically 
with  Solution  No.  2  before  the  incision  is  made  or 
a  second  coat  of  tincture  of  iodine,  or  else  Solution 
No.  1  is  applied  instead.  For  vaginal  operation, 
warm  1-1000  aqueous  lysol  or  else  soft  soap  and 
warm  sterile  water  cleansing.  To  diminish  the  slip- 
periness  of  the  mucous  membrane,  rinsing  with 
tannic  acid  or  zinc  sulphate  1-100,  or  bichloride  of 
mercury  1-1000,  may  follow  the  cleansing  procedure. 

The  'adoption  of  a  system  insures  greater  ac- 
curacy and  facilitates  clinical  study,  but  the  refrain 
that  must  come  to  every  clinician  who  has  been 
laboring  industriously  to  systematize  his  work,  is 
that  no  routine,  however  comprehensive,  can  be  ap- 
plied fitly  to  every  case. 


Procedure 

in  the  Operating 

Room 


CHAPTER  III 


Sterile  Wash  and  Wound  Dressings 


Sterilization  of 
Dressings 


Sterilization 

by  Steam 

Under 

Pressure 


It  is  scarcely  more  than  twenty-five  years  that 
the  antiseptic  methods  have  been  displaced  by  the 
aseptic  treatment  of  wounds.  Chemical  solutions 
of  sufficient  strength  to  destroy  bacteria,  and  even 
to  inhibit  their  growth  in  a  healing  wound,  become, 
at  the  same  time,  a  serious  menace  to  celi-develop- 
ment  and  proliferation,  and  interfere  vitally  with 
normal  tissue  repair.  It  was  the  full  realization  of 
this,  that  gradually  led  to  the  modern  conception  of 
aseptic  surgery,  and,  in  place  of  wound  dressings 
saturated  with  powerful  germicides,  there  was  in- 
troduced everywhere,  dry,  unimpregnated  gauze, 
sterilized  by  means  of  thermic  instead  of  chemical 
methods. 

Of  the  thermic  methods  of  sterilization,  the  sim- 
plesit  is  that  by  boiling,  but  in  the  case  of  operating- 
room  wash  and  wound  dressings  where  the  material 
should  be  dry  after  sterilization,  other  methods  had 
to  be  adopted.  In  the  most  practical  and  reliable 
of  these,  the  materials  are  subjected  to  the  steriliz- 
ing action  of  steam  under  pressure.  Many  appar- 
atuses, some  of  them  apparently  quite  complex, 
have  been  designed  for  this  purpose;  but  the  gen- 
eral principles  upon  which  their  construction  is 
based,  are  essentially  the  same. 

In  the  older  models,  the  steam  was  admitted  into 
the  sterilizing  space  immediately,  and  there  was  no 

(14) 


Guiding  Principles  in  Surgical  Practice       15 


particular  device  which  insured  the  proper  prelimi- 
nary warming  of  its  contents.  The  result  was,  that 
the  parcels  became  damp  or  wet  from  the  conden- 
sation of  the  superheated  steam  upon  the  cool  sur- 
face. To  correct  this,  the  mantle  of  newer  steriliz- 
ers consists  of  two  cylinders,  one  within  the  other. 
The  space  betiveen  them  can  be  filled  with  steam 
and  is  called  the  steam-jacket  space,  in  distinction 
to  the  space  within  the  inner  of  the  two  cylinders, 
the  sterilising  space.  After  the  nurse  has  packed 
the  sterilizing  space,  the  door  of  the  sterilizer  is 
closed  and  the  steam-jacket  space  is  filled  with 
steam.  As  soon  as  the  parcels  have  been  warmed 
sufficiently,  superheated  steam  is  admitted  to  the 
sterilizing  space  itself,  to  take  the  place  of  the  dry 
heated  air  which  it  contains. 

When  the  sterilization  is  complete,  the  residual 
steam  is  removed  from  the  compartment.  To  ac- 
complish this,  a  separate  valve-mechanism  is  at- 
tached to  the  sterilizer,  by  means  of  which  the 
residual  vapor  can  be  disposed  of  by  exhaustion. 
The  same  device  also  makes  it  possible  to  get 
rid  of  the  warm  air  at  the  beginning  of  the  sterili- 
zation process,  without  depending  on  the  incoming 
steam  to  displace  it.  This  provision  effectively  does 
away  with  the  occasional  wet  bundles  delivered 
from  the  older  sterilizers,  and  insures  thorough  dry- 
ness of  the  wash  and  dressings  after  sterilization. 

Briefly  stated,  the  process  of  sterilization  by 
steam  under  pressure  involves  the  following  steps: 

I.     Packing  of  the  sterilizing  space. 

II.     Warming  of  the  wash  to  prevent  condensa- 
tion. 


Construction 
of  the 
Sterilizer 


Steps  in 
Sterilization 


16      Guiding  Principles  in  Surgical  Practice 


Time 
Required 


Reason  for 
Resterilization 


III.  Exhausting  the  air  and  filling  the  compart- 

ment with  steam. 

IV.  Permeation  of  the  parcels  by  steam  under  a 

pressure  of  15  pounds  to  the  square  inch, 
and  at  a  temperature  of  250°  F.  (121°C.) 
for  30  minutes. 

V.     Final  drying  of  the  parcels;  the  desiccation 
taking  from  10  to  20  minutes. 

The  total  time  required  for  the  work  of  steriliza- 
tion in  preparing  for  an  operation  may  vary  con- 
siderably, and  usually  exceeds  an  hour.  But  the 
time  consumed  by  the  actual  sterilization  itself,  with 
the  thermometer  registering  250°  F.,  and  the  man- 
ometer indicating  a  pressure  of  15  pounds,  should 
never  he  less  than  50  minutes.  Practically  speak- 
ing, in  hospital  routine,  the  contents  of  each  parcel 
have  been  subjected  to  the  sterilization  process 
twice  before  they  are  used  at  an  operation.  It  is 
the  practice  to  sterilize  the  contents  of  the  parcels 
immediately  after  they  have  been  made  up  to  be 
put  away  in  the  parcel  closet.  When  needed  they 
are  resterilized,  and  can  then  be  taken  directly  from 
the  sterilizer  for  use. 

One  object  of  this  double  sterilization  is  to  at- 
tack spores,  which  initially  show  considerable  re- 
sistance. But  liberated  and  made  to  germinate, 
these  are  more  likely  to  be  destroyed  during  the 
second  sterilization.  Fortunately,  the  pathogenic 
organisms  which  most  commonly  produce  wound 
infection  are  cocci,  streptococci,  staphylococci, 
pneumococci,  gonococci,  and  have  no  spore-forms; 
the  bacillus  pyocyaneus  and  colon  bacillus  are  not 


Guiding  Principles  in  Surgical  Practice      17 


spore-bearing,  while  the  tetanus  bacillus  which  pro- 
duces spores  is  of  infrequent  occurrence. 

If  any  articles,  such  as  towels  or  gloves,  are 
known  to  have  been  soiled  with  pus,  for  example 
at  an  unclean  operation,  it  is  always  wisest  and 
safest  to  attend  to  their  sterilization  promptly,  by 
boiling  them.  Ten  to  fifteen  minutes  in  slightly 
alkaline  or  twenty  to  twenty-five  minutes  in  plain 
water  is  adequate.  When  wanted  again  for  opera- 
tion these  articles  can  be  resterilized  by  steam  under 
pressure  in  the  usual  manner,  and  a  transferrence 
of  pathogenic  germs  from  one  case  to  the  other, 
need  not  be  feared.  The  initial  boiling  is  resorted 
to  in  such  cases,  because  boiling  is  the  simplest  and 
most  reliable  of  all  methods  of  sterilization. 

The  greatest  scruple  is  necessary  in  case  of  the 
rubber  gloves,  because  they  come  into  the  most  in- 
timate contact  with  the  wound.  A  gauze  drain  is 
put  into  each  glove  in  order  to  keep  it  from  collaps- 
ing. As  a  rule,  alkaline  solutions  are  more  apt  to 
destroy  the  elasticity  of  the  rubber  gloves  than  plain 
water ;  but,  if  time  is  a  factor,  instead  of  using  plain 
water,  gloves  may  be  boiled  from  10  to  15  minutes 
in  a  1-1000  aqueous  solution  of  sodium  hydrate 
(NaOH)  ;  in  fact,  this  may  be  done  a  number  of 
times  before  their  texture  is  materially  impaired, 
and  the  gloves  become  brittle  and  lose  their  elas- 
ticity. Ordinarily  gloves  are  boiled  in  plain  water 
from  20  to  25  minutes.  After  boiling  they  are  at 
once  thoroughly  dried  and  powdered,  and  are  then 
ready  for  resterilization  by  steam  under  pressure. 
In  making  rounds  through  the  hospitals,  a  remark- 
able diversity  of  opinion  can  be  gathered  on  this 


Disposal 
of  Soiled 
Wash 


Sterilizing 

Rubber 

Gloves 


18       Guiding  Principles  in  Surgical  Practice 


Time 

Required  by 

Different 

Methods 


Parcels 

Must  Be 

Permeable 


subject.  There  seems,  however,  no  tenable  reason 
why  rubber  gloves  should  not  be  resterilised  by 
steam  under  pressure,  in  the  same  manner  as  the 
operating-room  wash  and  wound  dressings.  Of 
course,  during  the  steam  sterilization,  just  as  dur- 
ing sterilization  by  boiling,  it  is  important  that  a 
gauze  drain  be  placed  into  each  glove  so  that  the 
circulating  steam  can  have  access  to  its  interior. 
Furthermore,  stickiness  or  adhesion  of  the  gloves 
is  entirely  obviated  if  the  surfaces  have  been  we'll 
powdered  before  they  are  subjected  to  the  super- 
heated vapor. 

In  substituting  one  method  for  the  other,  the 
comparative  time  required  for  sufficient  steriliza- 
tion in  each  case,  has  to  be  borne  in  mind.  It  is 
indicated  in  the  following  table : 

Boil  in  alkaline  water  (104°  C.)  5-10-15  minutes. 
Boil  in  plain  water  (100°  C.)  20-25  minutes. 
Steam  at  250°  F.  (121°  C.)  35  minutes. 
Steam  at  212°  F.  (100°  C.)  45  minutes. 

With  regard  to  the  size  of  the  parcels  and  the 
manner  of  packing  the  'sterilizer,  there  are  a  few 
points  which  are  of  practical  importance.  The 
sterilizer  should  not  be  packed  too  tightly  if  the 
steam  shall  circulate  freely  between  the  parcels. 
To  further  facilitate  penetration,  the  individual 
bundles,  above  all,  if  they  are  somewhat  compact, 
should  not  be  made  larger  than  necessary.  The 
parcel  wrappers  should  be  of  strong  cloth  which 
is  adequately  porous;  covers  of  rubber  or  of  other 
impermeable  materials,  paper  bags  or  envelopes, 
are  never  to  be  used  as  containers  for  anything  that 


Guiding  Principles  in  Surgical  Practice       19 


is  to  ibe  sterilized.  The  importance  of  this  is  not 
infrequently  lost  sight  of  in  the  sterilization  of 
talcum-powder,  which  finds  its  way  into  the  steril- 
izer in  receptacles  of  wood,  glass,  tin  or  paper.  Al- 
though these  receptacles  may  be  provided  with 
small  perforations  at  one  end,  the  free  access  of 
the  steam  is  unnecessarily  impeded.  The  result 
may  be  insufficient  sterilization  of  the  contents,  and 
the  direct  trans ferrence  of  pathogenic  organisms  to 
the  wound.  If  the  surgeon  insists  upon  having  tal- 
cum sterilized  separately,  small  quantities  of  it 
should  be  put  into  pockets  or  bags  of  cloth.  How- 
ever, where  stress  is  laid  on  powdering  the  rubber 
gloves  properly  before  sterilization,  and  the  sur- 
geon takes  time  to  dry  his  hands  thoroughly  with 
a  sterile  towel  before  attempting  to  put  them  on, 
the  demand  for  an  extra  supply  of  talcum  becomes 
redundant. 

What  should  the  sterilized  bundles  for  the  ordi- 
nary, uncomplicated  laparotomy  contain?  The 
nurse  has  in  readiness,  a  supply  which  is  sufficient, 
firstly,  for  the  patient,  secondly,  for  the  surgeon, 
assistants  and  nurses  who  help  at  the  operation.  In 
an  interval  operation  for  appendicitis,  where  only 
one  assistant  at  the  wound  is  needed  besides  the  an- 
esthetist, and  one  operating-room  nurse  who  has 
charge  of  the  instruments,  suture  material  and 
gauze,  the  number  of  sterile  gowns  required  is  ac- 
cordingly small.  Desirable  are  gowns  with  long 
sleeves  over  the  cufTs  of  which  the  rubber  gloves 
can  be  drawn  so  that  the  arm  is  entirely  covered.  A 
very  practical  receptacle  for  sterile  gowns,  which  is 
in  use  in  some  of  the  operating-rooms  in  this  city, 


Sterile  Talcum 
Powder 


Contents 
of  the 
Sterilized 
Package 


Operating 
Gowns 


20      Guiding  Principles  in  Surgical  Practice 


Rubber 
Gloves 


Laparotomy 
Sheet 


Towels 


is  a  metal  drum,  the  cover  of  which  can  be  raised 
whenever  a  sterile  gown  is  needed,  by  stepping  on 
a  pedal  at  the  base  of  the  stand  on  which  it  rests. 
As  soon  as  the  pressure  with  the  foot  is  released, 
the  lid  of  the  drum  again  drops  back  into  place. 

There  should  be  seamless  rubber  gloves  of  the 
proper  size  to  fit  all  those  concerned  in  the  opera- 
tion. Their  number  should  be  ample  to  allow  for 
one  change  for  each  assistant  and  nurse  and,  if  oc- 
casion should  demand,  two  for  the  surgeon.  The 
asepsis  can  be  logical  only  if  gloves  are  worn 
throughout  the  entire  operation,  and  by  all  who 
come  in  contact  with  the  sterile  materials  and  in- 
struments. This  means  that  the  nurse  who  arranges 
the  supply-table  and  consequently  touches  the  ster- 
ile gauze,  instruments  and  suture  materials,  can  do 
this  only  with  rubber  gloves. 

The  laparotomy  sheet  should  be  large  enough  to 
cover  the  whole  patient,  besides  draping  the  oper- 
ating table  on  each  side ;  it  has  an  opening  over  the 
field  of  operation.  A  T-shaped  opening  in  the  cloth 
is  more  serviceable  for  the  various  incisions  than 
a  longitudinal  one.  This  is  particularly  apparent 
when  a  transverse  incision,  such  as  the  semilunar 
hypogastric,  is  used  by  the  surgeon. 

After  the  laparotomy  sheet  is  adjusted,  four 
towels  surround  the  wound  site.  There  should  be 
sufficient  for  one  renewal,  and  an  extra  dozen  for 
other  needs.  The  surgeon  asks  for  towels  for  his 
hands,  a  toweb  or  two  are  wanted  to  dry  the  ab- 
domen after  the  cleansing  measures,  another  wraps 
the  heft  of  the  Pacquelin  cautery.  Where  one  nurse 
is  able  to  take  charge  of  the  instruments  and  sterile 


Guiding  Principles  in  Surgical  Practice      21 

gauze,  there  is  no  advantage  in  covering  more  than 
one  supply-table.  Sterile  gauze  and  towels,  suture 
material,  needles  and  needle-holders,  Michel's 
clamps,  retractors,  forceps,  clamps  and  hemostatics,  Arrangement 
and  cutting  instruments,  can  all  be  placed  on  one  °^  ^^^ 
long,  narrow  table  in  orderly  fashion,  and  kept  sep-  "^^  ^ 
arated  from  one  another.  When  the  surgeon  pre- 
fers to  pick  the  instruments  himself,  directly  from 
a  Hartley  table  which  is  pushed  up  close  to  the 
field  of  operation,  a  suitable  cover  or  slip  which  fits 
the  instrument-tray  can  be  added  to  the  sterilizer 
supply.  A  wet  instrument  should  always  be  dried, 
before  it  is  laid  down  upon  the  supply-table.  If 
the  cover,  which  often  consists  of  a  single  layer  of 
cloth,  is  accidentally  saturated  by  dropping  a  bundle 
of  wet  suture  material  upon  it,  diffusion  currents 
are  set  up  at  once  from  the  surface  of  the  unsterile 
glass  plate  beneath,  to  the  suture  which  lies  in  the 
wet  area.  Such  a  suture  is  quickly  soiled,  and  must 
be  discarded.  It  is  safest  to  put  all  the  suture  ma- 
terials on  a  small  tray  of  agate-ware  which  has  been 
sterilized  with  the  instruments  for  this  purpose. 

There  need  not  be  a  great  variety  of  sterilized 
gauze.  The  tiny  gauze  sponges  should  be  elimi- 
nated, since  they  are  apt  to  be  lost  in  the  wound. 
It  is  better  to  cut  very  small  pieces  of  gauze  as  oc- 
casion requires.  The  gause  sponges  should  be 
2y^  X  2^  inches,  and  certainly  not  larger  than  Gauze 
3x3  inches.  The  gauze  should  be  so  folded  into  Sponges 
a  square,  that  the  cut  edge  of  it  nowhere  shows 
fraying  with  the  liberation  of  little  threads,  or,  un- 
folding does  not  take  place  while  it  is  handled.  It 
should  be  at  least   four-ply,  so  that,  when  it  is 


22      Guiding  Principles  in  Surgical  Practice 

folded  diagonally — delta  sponge — it  is  eight-ply. 
In  this  form  it  serves  its  purpose  as  a  sponge  most 
efficiently,  which  is  chiefly  to  imbibe  fluids — secre- 
tions, blood  or  puis.  The  delta  sponge  is  picked  up 
in  such  a  manner  that,  to  resort  to  geometrical  ver- 
biage, the  blades  of  the  long  thumb  forceps  are  par- 
allel to  the  hypothenuse  of  this  triangular  piece  of 
gauze.  The  nurse  should  understand  this,  since  she 
may  be  asked  to  fix  the  sponges  in  the  sponge- 
holder  in  this  way,  or  else,  to  hand  them  to  the 
surgeon's  forceps  individually. 

When  more  appreciable  quantities  of  fluid  have 
to  be  dealt  with,  as,  for  example,  in  the  bursting 
of  an  abscess  or  cyst  during  operation,  the  gauze 
sponge  may  have  to  be  replaced  by  pieces  of  gauze 
which  have  a  greater  bulk  and  proportionately  in- 
creased  imbibing  power.  Large  pieces  of  gauze 
Tampons  "^^^  ^^^°  ^^  called  into  play  in  exhausting  a  small 
transudate  or  exudate,  or  in  removing  accumulated 
blood.  In  the  case  of  profuse  oozing  from  an  in- 
cision, as  when  operating  for  cancer  of  the  breast, 
large  pieces  of  gauze  packed  into  the  bleeding  fur- 
row, effect  prompt  hemostasis  and  prevent  undue 
loss  of  blood.  In  a  sudden  venous  hemorrhage  in 
the  depth  of  the  abdomen  or  pelvis,  where  the  in- 
jured vessel  is  not  at  once  manifest,  firm  tamponade 
with  large  pieces  of  gauze,  is  the  emergency 
measure.  Rarely,  and  in  modern  surgery,  only 
when  this  cannot  be  circumvented,  a  large  piece  of 
gauze  may  be  inserted  into  the  abdomen  or  pelvis, 
to  "act  as  a  drain" — really  a  foreign  body  around 
which  adhesions  of  the  intestinal  loops  rapidly  form 
on  account  of  the  destruction  of  the  surface  endo- 
thelium, so  that  when  the  gauze  is  removed,  in  the 


Guiding  Principles  in  Surgical  Practice      23 

course  of  five  to  seven  days,  a  securely  walled-off 
canal  or  conduit  remains,  which  leads  down  to  the 
suspected  focus.  For  all  these  exigencies  larger 
pieces  of  gauze  folded  into  four-ply  tampons,  4x16 
inches,  and  gathered  into  accordeon  pleats — accor- 
deon  gauze  tampons — can  be  fitly  employed. 

Besides  gauze  sponges  and  tampons,  there  are 
required  in  the  ordinary  laparotomy,  about  a  dozen 
abdominal  pads.  These  are  intended  only  for  wall- 
ing-off  the  intestines,  or  for  protecting  the  viscera  Abdominal 
from  traumatism  or  contamination.  The  abdominal  Pads 
pad  is  also  made  of  surgeon's  gauze  which  is,  how- 
ever, sewn  into  a  square,  12  x  12  inches,  with  a  tail 
of  cord  or  tape  2  inches  long,  and  a  metal  ring  at- 
tached to  one  of  the  corners.  It  is  not  intended  to 
absorb  secretions,  and  should  not  be  bulky  nor  have 
a  thick  edge,  and  therefore  consists  of  only  three 
layers  of  gauze.  The  capillarity  of  the  gauze,  and 
the  friction,  make  it  a  little  difficult  to  introduce 
such  a  pad,  but  after  it  is  finally  placed  in  situ,  it 
has  the  decided  advantage  that  it  is  not  as  readily 
dislodged  by  the  abdominal  breathing,  intestinal 
peristalsis,  and  the  surgeon's  manipulations,  as  a 
pad  made  of  some  smooth  material  would  be.  To 
facilitate  the  placing  of  an  abdominal  pad,  the  as- 
sistant should  hold  it  up  suspended  by  the  ring, 
while  the  surgeon  grasps  the  most  dependent  cor- 
ner with  the  long  thumb  forceps  in  his  right  hand, 
holding  the  intestinal  coils  or  viscus  in  question  out 
of  the  way  with  the  left. 

Although  it  is  not  imperative,  it  is  practicable  to 
have  both  the  materials  for  cleansing  the  area  of 
operation,  and  those  used  for  the  final  dressing  of 


24      Guiding  Principles  in  Surgical  Practice 

the  wound,  put  up  in  separate  parcels.     For  the 

Gauze  for    scrubbing  manipulations  the  assistant  wears  sterile 

Cleansing    rubber  gloves,  and  the  territory  immediately  sur- 

an        ina     j-Qunding  is  covered  with  sterile  towels.     In  scour- 
Dressing  °  . 

ing  the  abdomen  the  piece  of  gauze  used  should  be 

large  enough  to  fill  the  hand — a  square  yard  of 
gauze  well  crimped,  yields  about  the  requisite  bulk 
to  make  its  handling  convenient.  Small  bits  of 
gauze  or  cotton  held  between  a  few  fingers,  cannot 
be  considered  in  earnest  attempts  to  render  a  large 
surface  clean.  For  the  application  of  alcohol  and 
the  subsequent  drying,  two  small  pieces  of  gauze 
each  about  half  a  yard  square  will  do.  In  all,  no 
less  than  four  pieces  of  crimped  gauze — two  large 
and  two  smaller  ones — should  constitute  the  content 
of  this  parcel,  when  the  soap  and  water  routine  is 
followed. 

The  use  of  aseptic  gauze  in  place  of  the  anti- 
septic, for  wound  dressings,  simple  and  plausible  as 
it  may  seem,  is  nevertheless  the  outcome  of  a  com- 
plicated evolution.  This  demonstrates  again,  what 
has  been  the  case  with  many  of  the  fundamental 
conceptions  in  the  practice  of  surgery,  which  at  the 
present  time,  after  their  unencumbered  exposition 
by  our  teachers,  appear  almost  self-evident. 

For  wound  dressing,  aseptic  gauze,  dry  and  por- 
ous, is  the  best  material.  Indeed,  many  clean 
wounds  would  not  have  to  be  dressed  at  all,  were 
it  not  for  fear  of  an  injury  to  the  delicate  suture- 
line,  or  the  risk  of  contamination  from  without, 
before  it  has  had  time  to  become  naturally  sealed 
by  the  healing  process.  Even  after  the  most  pains- 
taking apposition,  occasionally  there  may  be  slight 


Guiding  Principles  in  Surgical  Practice      25 

oozing  from  the  line  of  the  incision;  but  the  gauze 
dressing  serves  to  take  up  the  secretion  at  once,      The 
and  keeps  the  wound  dry,  while,  at  the  same  time,      Dry  Aseptic 
it  admits  of  sufficient  ventilation  to  keep  the  covered      Dressing 
skin  in  a  healthful  state.     To  secure  the  maximum 
aeration,  the  piece  of  gauze  which  is  in  direct  con- 
tact with  the  wound,  should  always  be  a  crimped 
piece.     Four  to  eight  such  pieces,  each  half  a  yard 
square,  may  be  applied,  depending  on  the  case.    The 
bulkier   dressings    are    sometimes    used    as    elastic 
pads,  to  prevent  the  accumulation  of  serum  or  blood 
where  this  is  anticipated.     A  square  of  uncrimped 
gauze  or  a  folded  towel  may  be  chosen  as  a  cover, 
but  never,   impermeable  material,  such  as  rubber 
tissue,  except  where  there  is  a  special  indication, 
as  for  example,  where  there  is  danger  of  soiling  the 
dressing  from  without,  by  dejecta  or  urine.    It  can 
be  readily  illustrated   in  the  laboratory,  how  the 
mere  drying  process  inhibits  the  development  of  a 
colony  of  bacteria.    That  warmth  and  moisture,  on 
the  other  hand,  are  vital  to  bacterial  growth,  is  a 
surgical  platitude.     Normally  an  invisible  evapor- 
ation takes  place  from  the  dressing,  and  the  sur- 
face is  thereby  cooled.    An  enclosure,  impermeable 
to  moisture,  causes  the  atmosphere  in  the  dressing 
to  stagnate,  and  the  secretions  to  decompose,  and 
provides  the  conditions  necessary  for  the  rapid  in- 
cubation of  germ-life. 

This  analysis  of  the  sterile  wash  and  gauze 
needed  at  an  operation,  is  given  in  considerable  de- 
tail, in  order  to  facilitate  a  clear  understanding  in 
this  matter,  between  the  surgeon  and  the  niirse. 
Precision  in  such  things  as  these,  is  the  hasis  of  a 
reliable  operating-room  service. 


26      Guiding  Principles  in  Surgical  Practice 

The  nurse's  list  of  supplies  for  one  laparotomy : 
urse  s        3  to  6  head  covers,  and  gowns,  for  doctors  and 
Supplies    nurses. 

for  One        7  to  9  pairs  of  rubber  gloves,  and  2  to  4  pairs  of 
Laparotomy    half -gloves. 

1  laparotomy  sheet. 

2  dozen  towels. 

2  covers  for  the  supply-table. 
y2  gross  of  gauze  sponges. 
2  dozen  gauze  tampons. 
1  dozen  abdominal  pads. 
1  parcel  scrubbing  gauze. 
1  parcel  dressing  gauze. 

To  a  certain  degree,  the  operating-room  nurse 
may  exercise  her  natural  inventiveness,  in  the  get- 
up  of  this  stock  of  supplies  for  an  operation;  but 
she  should  never  allow  variety  in  design  to  impair 
the  utility  of  an  innovation.  In  general,  in  the  pur- 
suit of  asepsis,  it  is  not  complexity  and  multiplicity, 
but  simplicity  and  uniformity,  that  are  most  de- 
sirable. 


CHAPTER  IV 

The  Sterilization  of  Utensils  and  Instruments 
FOR  Operation 

It  has  long  ago  been  determined  that  sterilization 
by  boiling,  is  far  more  reliable  than  sterilization  by 
disinfection,  and  the  practice  of  attempting  to  render 
operating-room  utensils  aseptic  by  other  means  has 
largely  been  abolished.  Every  well  equipped  oper- 
ating-room should  have  a  separate  utensil  steriliser.  The 
It  should  not  be  a  small  modd,  but  of  such  dimen-  Utensil 
sions  that,  without  exception,  every  article  in  the  Sterilizer 
operating  theatre  which  directly  or  indirectly  might 
come  in  contact  with  sterile  solutions,  materials  or 
instruments,  or  the  gloved  hands  of  the  surgeon,  has 
room  in  it.  This  includes  all  containers  and  recep- 
tacles intended  for  use  at  the  operation,  basins  or 
tanks  for  sterile  solutions,  trays  for  materials  and  in- 
struments, and  also  the  plates  of  the  operating  and 
supply  tables.  Glass  is  heavy,  easily  chipped  and 
fragile.  Agate  ware,  though  less  attractive,  is  much 
more  serviceable.  The  customary  glass  panels  on 
operating  tables  are  easily  dislodged  and  broken,  and 
could  well  be  replaced  by  plates  of  agate  or  enameled 
ware  which  are  not  laid  into  a  framework  like  panels 
•but  cover  the  underlying  supports,  and  can  be  re- 
moved and  rendered  absolutely  sterile  by  boiling. 
Similarly,  there  might  be  substituted  in  place  of  the 
glass  top  of  the  supply  table,  a  plate  of  the  same  ware 
consisting  of  a  number  of  smaller  segments  with 
shallow  interlocking  grooves,  so  that  they  can  be 
(27) 


28      Guiding  Principles  in  Surgical  Practice 


folded  upon  each  other,  or  detached,  and  put  into 
the  sterilizer. 

Under  the  heading   of   operating-room   utensils 
are  comprehended : 


Operating 

Room 

Utensils 


Provision  for 
Cleansing 
the  Hands 


1.  Containers  for  sterile  solutions. 

2.  Utensils  required  during  the  scrubbing  of  the 

patient,  and  for  irrigation. 

3.  Receptacles  for  waste  materials,  and  bacterial 

discharges. 

In  the  modern  operating-room,  where  ample  pro- 
vision is  made  for  the  mechanical  cleansing  of  the 
hands  and  arms  with  sterile  soft  soap,  sterile 
brushes  and  warm,  sterilized  running  water  from 
a  conveniently  situated  tap,  the  numerous  basins 
with  solutions  for  the  hands  become  superfluous. 
All  that  is  necessary  in  their  place,  is  one  sterile 
basin  containing  about  a  dozen  sterile  gauze  sponges 
saturated  with  strong  alcohol.  The  alcohol  is 
needed  to  locate  small  wounds,  to  remove  the 
residual  moisture  and  close  the  relaxed  pores,  after 
the  scrubbing  and  drying  of  the  hands  and  arms 
has  been  attended  to  with  due  care. 

On  each  side  of  the  operating  table,  within  easy 
reach,  there  should  be  a  basin  of  sterile  water  in 
which  the  gloves  may  be  rinsed  during  the  opera- 
tion. A  third  basin  is  reserved  for  the  nurse  at  the 
supply  table. 

In  general,  the  same  principles  that  are  followed 
in  preparing  the  hands  for  operation,  also  can  hold 
good  in  rendering  the  field  of  operation  surgically 
clean.  The  soap  and  water  routine  may  be  exactly 
the  same  except  that  here  gauze  is  preferred  by 
many  to  the  harsher  brush.  Consequently  the  ac- 
cessories are  also  few  in  number.     Warm  sterUe 


Guiding  Principles  in  Surgical  Practice      29 

water  from  an  irrigator  takes  the  place  of  running 
water.  After  drying,  a  little  strong  alcohol  is  al- 
lowed to  complete  the  dehydration  of  the  surface. 
For  this  another  small  sterile  basin  with  a  few 
gauze  sponges  soaked  in  alcohol,  is  kept  in  readiness 
by  the  nurse. 

The  irrigator  apparatus  referred  to,  consists  of  The 
two  reservoirs  or  tanks  of  agate  ware  each  holding  ^"igator 
not  less  than  a  gallon  of  fluid.  Connected  with  each 
of  these,  is  a  rubber  tube  at  the  end  of  which  is  a 
slender  metal  cannula  or  nozzle  with  a  stop-cock, 
to  regulate  and  control  the  flow.  The  tanks  are  sus- 
pended from  a  stand  on  which  they  can  be  easily 
raised  to  increase  the  hydrostatic  pressure,  or  low- 
ered for  the  convenience  of  the  nurse  in  refilling  or 
detaching.  The  refilling  of  the  tank  is  simple,  and 
can  be  done  best  by  means  of  a  sterile  pitcher.  The 
sterilization  of  the  tanks,  tubes  and  nozzles,  is  ac- 
complished before  the  operation;  both  irrigating 
apparatuses  are  disconnected  from  the  stand,  and 
boiled  together  with  the  other  utensils.  Pending 
their  use,  the  attached  nozzles  may  be  safely  lodged 
in  the  tanks  to  which  they  belong,  submerged  in  the 
irrigating  solution.  Sterile  water  fills  the  one,  the. 
other  contains  the  solution  indicated  by  the  surgeon, 
for  example,  tannic  acid  or  zinc  sulphate,  which  are 
to  act  as  astringents  to  facilitate  grasping  the  mu- 
cous membrane  in  a  vaginal  plastic,  acetone,  for 
bathing  a  cancerous  cervix,  or,  it  may  be  reserved 
for  physiological  saline,  for  intravenous  infusion, 
or  plain  sterile  water  for  hypodermoclysis  or  rectal 
feeding  during  operation. 

Large  quantities  of  fluid,  above  all,  if  they  are 
known  to  be  septic,  should  always  be  evacuated  into 
a  deep  vessel,  to  prevent  undue  splashing ;  the  ordi- 


30      Guiding  Principles  in  Surgical  Practice 

nary  pail  of  agate  ware,  advantageously  supplied 
with  a  wide,  grooved  nose-piece  to  facilitate  empty- 
ing, is  the  best  utensil  for  this  purpose.  Two  such 
Provision  pails,  one  placed  on  each  side  of  the  operating  table, 
tor  Septic  ^.^^  convenient  for  collecting  the  waste  materials, 
and  serve  to  remind  the  surgeon  and  his  assistants 
that  soiled  sponges  and  gauze  should  not  be  scat- 
tered promiscuously  about  the  floor  of  the  operating 
room. 

The  bean-shaped  pus-basin  has  retained  its  place 
as  a  useful  article,  because  its  form  makes  it  pe- 
culiarly adaptable  to  the  varying  curves  of  the  body. 
The  pus-pan,  really  a  modified  bed-pan,  which  can 
easily  be  pushed  under  the  patient,  and  upon  which 
any  part  of  the  body  can  rest  without  much  discom- 
fort, is  designed  especially  to  catch  the  pus  and  pre- 
vent avoidable  soiling  of  the  patient  and  the  operat- 
ing table.  Its  chief  use,  however,  is  in  office  and 
dispensary  surgery,  as  when  an  abscess  has  to  be 
opened  in  a  location  where  the  pus-basin  is  not 
practicable. 

Nurses  list  of  articles  to  be  boiled  in  the  utensil 
sterilizer : 

Nurse's       1.     The  folding  top  of  the  operating  and  the  sup- 
List  of  ply  tables. 

^     ,         2.  Two  small  alcohol  basins, 
to   be 

Boiled      ^-  S^^  basins  for  sterile  water. 

4.  Two   large   irrigating   cans   with   tubes   and 

nozzles. 

5.  Two  pitchers. 

6.  Two  pus-basins. 

7.  Three  pails. 

While  the  sterilization  of  operating-room  utensils 
by  boiling  in  alkaline  water,  and  their  adaptation  to 


Guiding  Principles  in  Surgical  Practice      31 

this  by  the  manufacturers,  is,  strange  as  it  may 
seem,    of    comparatively    recent   date,    the    routine  The 
sterilization  of  the  surgeon's  instruments  by  this  Surgeon's 
method,  and  the  elimination  of  ornate  hefts  and  de-  Instruments 
signs  which  were  difficult  to  keep  clean,  marks  the 
time  when  aseptic  surgery  really  began.    The  sterili- 
zation of  instruments  by  boiling  is  so  easily  accom- 
plished, that  it  required  but  little  more  than  the 
proof  of  its  unequalled  reliability  to  win  for  it  a 
permanent  endorsement. 

Boiling  water  is  all  that  is  needed.  Almost  any 
container  can  be  used  as  a  sterilizer;  its  shape  and 
construction  are  only  of  secondary  importance,  fhe 
The  water  is  made  slightly  alkaline,  to  prevent  the  Method  of 
rusting  of  the  metal.  For  this  end,  caustic  soda,  Sterilizing 
that  is,  sodium  hydroxide  (NaOH),  which  can  be  Instruments 
obtained  everywhere  in  the  form  of  sticks  contain- 
ing  about  90  per  cent,  of  the  water-free  sodium  hy- 
droxide, is  to  be  preferred.  It  is  practically  odorless, 
and  very  convenient  to  handle.  To  a  thousand  parts 
of  water,  one  part  of  sodium  hydroxide  will  generally 
suffice.  Certainly,  in  exceptional  instances,  as  in  the 
case  of  rain-water  which  contains  much  organic 
matter  and  carbonic  acid,  or  is  contaminated  with 
sulphur,  as  in  some  districts  where  soft  coal  is 
burned,  as  much  as  ten  parts  to  the  thousand — 1 
per  cent. — may  have  to  be  allowed.  Nothing  is 
gained  usually  by  increasing  the  alkalinity  beyond 
the  point  necessary  to  prevent  oxidation  of  the  in- 
struments. On  the  other  hand,  rubber  goods,  bags, 
tubing — in  the  event  that  this  should  be  advantage- 
ous— may  be  boiled  along  with  the  instruments  with 
comparative  impunity,  if  the  solution  is  not  too 
strongly  alkaline;  but  very  caustic  solutions  would 
soon  destroy  them. 


,   32      Guiding  Principles  in  Surgical  Practice 

The  time  required  to  render  instruments  unques- 
tionably aseptic,  varies  with  the  nature  of  the  con- 
The  taminating  organisms.  Some  of  the  ordinary  pyo- 
Time  genie  bacteria  possess  but  Httle  resistance  and  suc- 
cumb quickly  to  the  action  of  alkaline  water  at  the 
boiling  temperature.  Five  minutes  may  suffice  to 
make  these  inert.  It  is  the  spore-bearing  bacilli 
chiefly,  which  complicate  the  problem  of  steriliza- 
tion. The  average  time  it  takes  to  destroy  most  of 
these  has  been  experimentally  fixed.  A  representa- 
tive member  of  the  group  is  the  tetanus  bacillus, 
Not  only  do  its  spores  possess  the  characteristic  re- 
sistance to  a  pronounced  degree,  but  besides,  they 
are  developed  rather  rapidly,  that  is,  at  body  tem- 
perature, often  within  twenty  hours.  From  the 
behavior  of  these  spores  when  subjected  to  the  de- 
structive action  of  thermic  agents,  the  average  time 
necessary  for  reliable  sterilization  in  general,  can  be 
deduced.  Reasoning  on  this  basis,  it  may  be  said, 
that  if  a  germ-laden  instrument  is  boiled  in  alka- 
linized  water  for  fifteen  minutes,  its  sterility  is 
insured  with  reference  to  all  the  organisms  which 
are  commonly  responsible  for  a  wound  infection. 
It  scarcely  needs  to  be  added  that  this  presupposes 
that  the  water  is  boiling  actively  during  the  entire 
specified  time,  that  the  instruments  are  all  com- 
pletely submerged,  and  that  the  sterilizer  is  covered, 
to  prevent  undue  lowering  of  the  surface  tempera- 
ture of  the  boiling  water. 

Where  resterilization  is  regularly  practiced,  as  it 
should  be,  an  additional,  although  strictly  speaking, 
as  far  as  the  survival  of  spores  is  concerned,  ordi- 
narily a  negligible  safeguard  is  provided.  Thus 
routine  resterilization  is  advocated  as  a  prophylac- 
tic measure  to  meet  the  demand  of  the  exceptional. 


Guiding  Principles  in  Surgical  Practice      33 


not  of  the  usual  case.  An  instrument  that  has  re- 
cently been  in  contact  with  a  case  which  is  known 
to  have  developed  a  tetanus  infection,  is  not  used 
after  a  single  sterilization  of  fifteen  minutes  be- 
caiise  it  is  chiefly  for  these  spore-bearing  bacilli  that 
resterilization  may  be  of  value.  If  such  an  instru- 
ment cannot  be  temporarily  dispensed  with,  on 
account  of  some  unalterable  emergency,  the  only 
alternative  to  supplant  in  a  way,  although  imper- 
fectly, the  peculiar  action  of  resterilization  after  a 
day's  interval,  would  be,  to  double  the  length  of  the 
boiling  time.  In  this  connection  it  is  also  noteworthy 
that  the  spores  of  the  tetanus  bacillus  are  but  slightly 
affected  by  the  drying  process  which  is  otherwise  so 
inimical  to  bacterial  life.  It  is  possible,  for  example, 
that  an  instrument  may  convey  living  tetanus  spores 
to  a  wound,  two  years  after  its  contamination. 
This  view  of  the  persistence  of  tetanus  spore  life,  is 
also  tenable  in  the  case  of  the  dust  of  the  operating 
room  where  the  unfortunate  patient  has  been 
treated. 

The  fact,  that  almost  any  kind  of  receptacle  can 
fulfil  the  function  of  a  sterilizer  for  surgical  instru- 
ments, is  of  especial  moment,  when  emergency  sur- 
gery has  to  be  done  where  proper  facilities  are 
wanting.  But  even  in  hospital  practice,  the  most 
serviceable  instrument-sterilizers  are  of  relatively 
simple  construction.  A  useful  device  consists  of  a 
lever  which  is  connected  with  a  pedal  at  the  base  of 
the  stand  on  which  the  sterilizer  rests.  If  the  pedal 
is  depressed  with  the  foot,  the  tray  is  lifted  out  of 
the  sterilizer-tank.  This  allows  the  boiling  v^ter  to 
drain  off,  and  the  instruments  to  become  dry,  while 
the  temperature  falls  sufficiently  to  permit  handling 
and  arranging  them  on  the  supply  table. 


Object  of 
Resterilization 


The 

Instrument 

Sterilizer 


34      Guiding  Principles  in  Surgical  Practice 


Sterilizing 

Cutting 

Instruments 


While  there  is  unanimity  of  opinion  as  to  the 
proper  sterilization  of  metallic  instruments  in  gen-- 
eral,  in  the  case  of  cutting  instruments,  particularly 
scalpels,  some  surgeons  have  allowed  a  dangerous 
latitude.  Surely  it  cannot  be  correct  to  be  more 
lenient  with  the  sterilization  of  a  scalpel  than  with 
other  instruments.  Of  all  instruments  it  is  the  one 
that  comes  into  the  most  intimate  contact  with  the 
wound  while  inflicting  it,  and  its  absolute  sterility 
must  be  beyond  question.  The  only  reason  for  this 
deviation,  seems  to  be  the  fear  of  impairing  mate- 
rially the  acumen  of  the  cutting  edge,  when  the 
knife  is  subjected  to  the  boiling  process.  The  ques- 
tion might  as  well  be  asked,  wihether  a  dull  blade 
should  be  preferred  to  a  sharp  one,  obtained  at  the 
risk  of  an  imperfect  asepsis.  With  the  clear  under- 
standing that  the  safety  of  the  patient  who  submits 
to  an  operation  at  the  surgeon's  hands,  is  largely  de- 
pendent upon  the  asepsis  which  is  practiced,  and  the 
asepsis  in  turn,  on  the  sterility  of  the  instruments, 
there  can  be  no  hesitation  about  the  answer.  Be- 
sides, although  it  is  undoubted,  that  the  blade  can 
be  noticeably  damaged  by  or  during  the  boiling, 
the  impairment  must  not  be  great,  if  proper  pre- 
cautions are  observed.  Firstly,  all  scalpels  ought 
to  be  boiled  encased  in  a  small  knife-tray,  which, 
while  allowing  water  to  have  free  access,  prevents 
the  jostling  of  instruments  against  their  sharp 
edges  during  the  process  of  ebullition.  Secondly, 
the  cutting  instruments  may  be  chilled,  by  sub- 
merging them  in  cold  alcohol  immediately  upon 
their  removal  from  the  sterilizer. 

Finally,  it  ought  to  be  an  inflexible  rule  of  sur- 
gical cleanliness,  that  no  instrument  which  has  been 
used  at  an  operation,  whether  the  case  is  known  to 


The 


Guiding  Principles  in  Surgical  Practice      35 

be  an  unclean  one  or  not,  shall  be  returned  to  the 
instrument-closet  without  the  proper  cleaning  and  instrument 
sterilization.  At  the  same  time,  damaged  instru-  Closet 
ments  are  laid  aside  for  repair,  cutting  instruments 
which  have  lost  their  keen  edge  must  be  sharpened, 
and  new  suture  materials  supplied  to  replenish  the 
deficit  in  the  stock.  Order  should  be  cherished  here, 
as  in  many  things  pertaining  to  the  practice  of  sur- 
gery, not  only  by  the  nurse  who  has  charge  of  the 
operating-room  or  office,  but  by  the  surgeon  him- 
self as  well,  preeminently  so,  if  he  makes  it  a  prac- 
tice to  operate  in  private  institutions  or  homes  or 
in  the  country,  and  must  occasionally  rely  entirely 
upon  his  own  equipment. 


CHAPTER  V 


The  Surgeon's  Hands 


Reasons 

for  Wearing 

Rubber 

Gloves 


One  of  the  lessons  which  most  of  us  have  learned 
in  our  schoolwork  in  applied  bacteriology,  is  that  the 
hands  are  generally  not  aseptic.  It  requires  a  very 
thorough  and  systematic  procedure  to  make  them 
clean.  After  the  ordinary  washing  it  is  usually  pos- 
sible to  obtain  a  culture  of  germs  from  the  finger- 
nails, or  interdigital  folds.  In  rendering  the  hands 
surgically  clean  these  places,  therefore,  are  given 
particular  attention.  Notwithstanding  this,  bac- 
teriological experience  shows  that  sometimes 
growths  may  be  obtained  from  as  much  as  five  per 
cent,  of  the  cases,  when  the  hands  of  all  concerned 
in  the  operation  are  tested.  The  reasons  are,  on  the 
one  hand,  that  bacteria  may  penetrate  the  deeper 
layers  of  the  epidermis  where  they  become  quite 
inaccessible  to  the  cleansing  measures,  and  the  diffi- 
culty is  enhanced  when  the  frequent  use  of  anti- 
septics has  made  the  skin  fissured  and  rough.  On 
the  other  hand,  the  secretions  of  the  skin  itself  are 
not  always  sterile.  The  procedure  that  is  found  to 
be  practicable  for  the  skin  of  the  patient,  is  not 
equally  well  adapted  for  the  surgeon's  bands.  Here 
the  timely  application  of  a  penetrating  and  efficient 
disinfectant  such  as  iodine,  in  order  to  reach  the 
deeper  strata  of  the  epidermis,  is  not  feasible.  In 
these  considerations  are  given  the  reasons  for  the 
evolution  of  the  idea  of  covering  the  hands  with 
thin  gloves  of  India  rubber  and,  at  the  present  time, 
the  wearing  of  well-fitting  gloves,  seamless,  elastic, 

(36) 


Guiding  Principles  in  Surgical  Practice      37 


impermeable  to  secretions,  is  thought  to  be  the  only 
practical  and  reliable  safeguard  against  the  possible 
transmission  of  infection. 

After  the  preliminary  trimming  of  the  finger- 
nails by  means  of  the  curved  nail-scissors,  the  hands 
and  arms  are  scrubbed  with  soft  soap  in  warm 
sterile  running  water.  Soft  brushes,  which  have 
been  sterilized  by  boiling,  are  best  suited  for  the 
purpose.  The  only  practical  rule  that  can  be  given, 
is  to  scrub  in  orderly  succession,  every  fold  and 
crevice  and  every  part  of  the  hand,  forearm  and 
elbow.  It  is  well  to  proceed  as  if  each  finger  were 
a  definite  geometrical  figure,  a  parallelopiped,  pre- 
senting a  volar,  dorsal,  lateral  and  mesial  surface, 
and  finally,  a  distal  end,  all  of  which  must  receive 
attention.  If  the  brush  is  deftly  used,  the  orange- 
wood  stick  can  be  dispensed  with  for  the  nails.  In 
going  from  one  finger  to  the  next,  the  interdigital 
folds  and  spaces  are  attacked,  both  from  the  volar 
and  from  the  dorsal  side  of  the  hand.  The  object 
of  the  warm  soap-suds  is  to  soften  the  superficial, 
germ-laden  layers  of  the  epidermis,  and  facilitate 
their  mechanical  removal.  The  bacterial  debris,  as 
it  is  set  free,  is  rinsed  away.  No  time  can  be  fixed 
for  this  manoeuvre.  Some  manipulate  more  dex- 
terously than  others,  but  it  is  hardly  wise  to  reduce 
the  time  to  less  than  two  minutes  for  each  hand. 
The  flushing  with  warm  sterile  water  continues  un- 
til all  the  soap  has  disappeared.  The  hands  and 
arms  are  then  rubbed  dry  by  means  of  a  rough 
sterile  towel ;  sponged  with  strong  alcohol^  for  one 
minute  and  dried  thoroughly.  After  this  prepara- 
tion, and  without  interpolation  of  the  usual  germi- 
cidal solutions,  the  hands  are  ready  for  the  rubber 
gloves. 


Preparing 
the  Hands 
for  Operation 


38      Guiding  Principles  in  Surgical  Practice 


Dressing 
Rotation 


Wet   or 
Dry  Gloves? 


In  the  customary  rotation  in  dressing  for  an  op- 
eration, the  cap  and  mouth-binder  are  donned  first. 
After  getting  the  hands  surgically  clean  in  the  man- 
ner outlined,  the  arms  are  slipped  through  the  long- 
sleeved  sterile  gown.  Finally  the  sterile  rubber 
gloves  are  put  on,  and  their  cufifs  drawn  up  over  the 
ends  of  the  sleeves,  so  that  no  part  of  the  operator's 
forearm  remains  exposed.  It  would  be  manifestly 
inconsistent  to  allow  the  bare  forearm  to  come  in 
contact  with  the  instruments,  sterilized  gauze,  or 
the  wound  itself,  while  the  hands  have  been  so  care- 
fully protected. 

The  gloves  may  be  worn  wet  or  dry.  They  are 
wet  or  moist  after  sterilization  by  boiling,  and  tend 
to  adhere  to  the  hand,  so  that  it  is  not  always  easy 
to  put  them  on  in  the  correct  way ;  that  is,  by  grasp- 
ing only  the  cuffed,  reverted  end  while  drawing  them 
over  the  hand,  and  thus  avoiding  any  contact  of 
the  bare  fingers  with  the  exterior  surface.  An  ex- 
pedient sometimes  resorted  to,  which  facilitates  the 
slipping  of  the  glove,  is  to  fill  it  with  sterile  water. 
From  the  point  of  view  of  asepsis,  this  method  is 
faulty.  Firstly,  some  or  all  of  the  water,  after 
bathing  the  hand,  returns  to  the  basin  containing  the 
other  glove.  Secondly,  in  pulling  the  glove  over  the 
end  of  the  long  sleeve  of  the  operating  gown,  the 
latter  is  likely  to  be  drenched,  and  diffusion  at  once 
takes  place  between  the  skin  of  the  forearm  and  the 
surface.  For  the  use  at  operations,  it  is  an  advan- 
tage to  have  gloves  which  are  dry  after  the  steriliza- 
tion. Therefore,  whenever  there  is  an  apparatus 
available  for  sterilizing  by  steam  under  pressure, 
the  gloves  are  subjected  to  this  process,  preparatory 
to  operation.  With  circulating-steam  under  fifteen 
pounds  pressure  at  a  temperature  of  250°  F.  (121° 


Guiding  Principles  in  Surgical  Practice      39 


C),  thirty  to  forty-five  mdnutes  are  sufficient.  Each 
pair  of  gloves  is  sterilized  in  a  cloth  holder  on  w^hich 
the  size  is  marked.  When  the  gloves  are  wanted, 
the  folder  is  opened  like  a  book;  and,  in  a  pocket 
on  each  side,  is  contained  a  glove  with  the  cuff 
turned  back,  dry  and  well  powdered,  so  that  it  can 
readily  be  slipped  over  the  hand.  The  gloves  which 
are  used  at  operations  go  through  a  definite  cycle. 
They  are  rinsed  in  hot  soap  suds  and  then  boiled  for 
twenty  to  thirty  minutes  in  plain  water  without  the 
addition  of  any  chemical.  This  is  done  in  order  to 
destroy,  at  once,  all  the  bacteria  which  may  adhere 
to  the  glove,  and  to  prevent  their  dissemination.  A 
point  worth  remembering  in  reference  to  the  efifec- 
tual  sterilization  of  rubber  gloves  by  boiling,  is  to 
insert  a  large  drain  of  gauze  into  each  glove  so  that 
it  will  not  collapse,  and  free  access  of  the  boiling 
water  to  its  interior  is  not  prevented.  Good  rubber 
resists  sterilization  by  boiling  in  plain  water  num- 
berless times  before  it  becomes  brittle  and  inelastic ; 
but  with  alkaline  solutions  it  deteriorates  more  rap- 
idly. When  the  gloves  have  been  boiled,  they 
should  be  thoroughly  dried  between  towels,  and 
powdered  with  talcum  before  they  are  put  away. 
These  gloves  are  not  only  sterilized  after  they  have 
been  soiled,  but  again  when  they  are  used;  the  sec- 
ond time,  preliminary  to  operation,  preferably  as 
indicated,  by  steam  under  pressure.  In  this  way, 
germinating  spores  would  also  be  destroyed,  which 
before  their  germination  might  have  resisted  even 
the  boiling  process. 

The  fact  that  it  is  always  a  difficult  matter  to 
sterilize  the  skin  after  it  has  been  soiled,  should  im- 
press forcibly  the  importance  of  avoiding  all  unnec- 
essary   contamination.      Fortunately,    the    bacteria 


Preparation 
of   Rubber 
Gloves  for 
Operation 


40      Guiding  Principles  in  Surgical  Practice 


Contact  o£ 

the  Surgeon's 

Hands 

with  Pus 


Sources 

of  Wound 

Infection 


which  most  commonly  are  found  to  inhabit  the  skin, 
are  not  very  pathogenic.  So  also  streptococci  picked 
up  with  the  dust  of  the  floor  of  the  operating-room, 
are  not  apt  to  be  as  virulent,  as  those  which  come 
directly  from  a  case  recently  infected.  It  is  well 
known  that  repeated  inoculations,  as  a  rule,  increase 
the  virulence,  while  the  drying  process  which  takes 
place  when  bacteria  are  disseminated  with  the  dust, 
tends  to  destroy  them.  Particular  care  should  be 
exercised  by  the  surgeon  at  all  times,  to  avoid  direct 
contact  of  the  bare  hands  zvith  pus  and  bacterial 
discharges.  Laxity  in  observing  this  vital  precau- 
tion, notably  in  dispensary  practice,  may  lead  to  the 
most  disastrous  result.  Here,  highly  infectious  pus 
is  evacuated  from  abscesses  and  phlegmons,  and 
soiling  of  the  hands  is  inevitable,  unless  they  are 
protected  by  means  of  rubber  gloves. 

The  surgeon  who  considers  it  his  duty  to  ensure 
an  uncomplicated  recovery  for  his  patient,  should 
be  mindful  of  the  channels  or  sources  from  which 
an  infection  could  be  transmitted.  Besides  the 
surgical  polyclinic  or  dispensary,  the  dressing  of  un- 
clean cases  in  the  wards  of  the  hospital,  and  in  one's 
private  service,  has  to  be  considered.  The  practice 
of  examining  gynecological  cases  vaginally  without 
rubber  gloves,  is  obsolete.  Again,  while  research 
work  on  animals,  and  in  the  bacteriological  labora- 
tory, is  sometimes  of  great  importance  in  bringing 
about  the  solution  of  practical  problems,  it  undoubt- 
edly increases  the  risk  of  conveying  pathogenic  or- 
ganisms to  the  operating-room. 

Because  he  comes  in  such  close  touch  with  the 
operating  field,  it  is  preeminently  the  surgeon  him- 
self who  should  keep  his  body  clean  and  free  from 
pus  foci.    If  he  should  be  afflicted  with  a  furuncle. 


Guiding  Principles  in  Surgical  Practice      41 


for  instance,  he  should  exercise  additional  precau- 
tions to  guard  his  asepsis.  A  gauze-binder  or  mask 
which  covers  the  operator's  mouth  and  nose  is  ad- 
visable in  every  celiotomy  or  synoviotomy,  and  im- 
perative in  cases  where  an  active  rhinitis  or  tonsil- 
litis exists.  It  is  undoubtedly  better  to  shave  the 
face,  or  at  least  the  chin ;  a  beard,  in  general,  is  a 
dangerous  ornament,  but  if  it  cannot  be  sacrificed, 
it  should,  by  all  means,  come  within  the  grasp  of  the 
mouth-binder  and  be  well  covered.  Drops  of  sweat, 
too,  that  run  down  the  face  and  reach  the  wound, 
may  contaminate  it,  and  give  rise  to  an  infection. 
If  the  hair  of  the  head  remains  uncovered,  detached 
hairs  laden  with  germs  may  fall  upon  the  operating 
field.  A  towel  bound  about  the  forehead  and  hair, 
or  a  snugly  fitting  cap,  serves  a  two-fold  purpose: 
it  encloses  the  hair  and  absorbs  the  perspiration 
from  the  brow. 

By  observing  the  well  founded  rules  for  obtaining 
strict  asepsis  at  operations,  the  only  factor  that  re- 
mains uncertain,  as  far  as  extrinsic  infection  is  con- 
cerned, is  the  skin  of  the  patient.  However,  if  the 
surgeon  and  his  assistants  and  nurses  do  not  wear 
rubber  gloves,  the  skin  of  all  these,  just  as  well  as 
the  skin  of  the  patient,  becomes  a  source  of  danger. 
Without  rubber  gloves  it  is  quite  impossible  for  the 
surgeon  to  guarantee  the  asepsis  of  his  own  hands, 
much  less  that  of  the  many  others  that  help  him. 
It  is  true,  that  the  use  of  bare  hands  often  simplifies 
the  technic,  especially  in  gastro-intestinal  opera- 
tions, and  as  a  matter  of  fact,  some  of  the  most 
skillful  technicians  work  without  gloves.  The  rea- 
son given,  is  that  the  slippery  glove  does  not  permit 
the  ready  grasping  and  handling  of  the  delicate  vis- 
cera.   Rubber  gloves  have  been  manufactured  with 


Personal 
Asepsis 


Objections 
to  the 
Rubber 
Glove 


42      Guiding  Principles  in  Surgical  Practice 

a  pappilated  or  corrugated  surface  or  with  a  silk- 
finish,  but  these  do  not  correct  the  disadvantage. 
To  slip  the  ordinary  cotton  glove  over  the  rubber 
one  is  tedious,  and  makes  the  fingers  too  bulky. 
Cots  of  thin  material  can  be  used  as  covers  for  the 
index  finger  and  thumb  of  the  rubber  glove  at  any 
time  during  an  operation,  but  unless  they  are  fas- 


tened or  anchored  to  the  wrist  in  some  way,  these 
are  readily  dislodged  during  the  manipulation,  and 
may  be  lost  in  the  wound. 
The  I  have  therefore  adopted  a  half -glove,  which  is 
Half-glove  made  of  very^  thin  unprinted  linen — or  cotton — 
lawn.     (See  figure.) 

It  fits  the  index  finger  and  thumb  snugly  and  a 
single  button  fastens  it  about  the  wrist.    Unlike  the 


Guiding  Principles  in  Surgical  Practice      43 


patterns  followed  in  making  leather  gloves,  both 
fingers  and  thumb  have  but  a  single  slender  seam  so 
as  to  secure  the  least  possible  interference  with  pal- 
pation. If  the  button  at  the  wrist  is  large  enough, 
it  can  be  easily  buttoned  or  unbuttoned  without  any 
assistance,  and  the  half -glove  can  be  quickly  donned 
or  removed.  Of  course,  it  must  fit  the  hand  accu- 
rately. If  the  fingers  are  too  long  the  tips  will  dou- 
ble upon  themselves.  The  linen-lawn  of  which  it  is 
made,  whether  it  is  wet  or  dry,  slips  readily  over 
the  smooth  surface  of  the  rubber  glove.  A  supply 
of  half -gloves  may  be  boiled  together  with  the  in- 
struments and  suture  material,  and  put  on  wet,  if 
the  usual  sterilization  with  steam  under  pressure  is 
not  convenient.  To  those  who  have  become  accus- 
tomed to  work  with  it,  the  half-glove  can  be  dis- 
tinctly useful  in  vaginal  plastics  or  whenever  blunt 
stripping  with  the  finger  is  necessary,  as  well  as  in 
grasping  and  fixing  the  structures  during  vaginal 
celiotomy,  femoral,  inguinal,  ventral  herniae  and 
operations  on  the  stomach  and  bowel.  The  half- 
glove  is  meant  to  be  worn  only  as  occasion  demands 
it.  In  an  exploratory  laparotomy,  for  example, 
while  searching  among  the  intestinal  coils  and  dia- 
phragmatic or  pelvic  organs  for  a  tumor,  the  half- 
glove  would  be  a  hindrance,  while  the  smooth  un- 
covered rubber  glove  enables  gentle  and  almost  f  ric- 
tionless  handling. 

Notwithstanding  a  dissenting  opinion  w^hich  is  oc- 
casionally expressed,  the  great  value  of  rubber 
gloves  in  preserving  a  rigid  asepsis  cannot  be  de- 
nied. Even  a  glove  with  a  few  tiny  perforations 
caused  by  a  needle  or  a  sharp  retractor  and  escap- 
ing notice,  is  far  better  than  no  glove  at  all.  Fur- 
thermore, if  the  tear  is  not  very  minute  it  is  seen  at 


Rubber 
Gloves 
are 
Indispensable 


44      Guiding  Principles  in  Surgical  Practice 

once,  and  it  is  a  simple  thing  to  change  the  damaged 
pair.  A  rubber  glove  of  good  quality,  if  it  is  not 
too  large,  but  fits  the  hand  properly,  will  stand  con- 
siderable wear.  The  tactile  sense  is  impaired  some- 
what, it  is  true,  but  surely  never  to  such  an  extent 
that  it  makes  the  difference  worthy  of  consideration. 
Training  ^^  short,  the  surgeon  is  constantly  living  in  a  di- 
in  lemma.  He,  more  than  others,  is  subjected  to  the 
Asepsis  opportunities  for  contaminating  his  hands  with 
virulent  germs;  he,  more  than  others,  should  keep 
his  hands  unpolluted  by  pus.  Not  merely  on  the 
theoretical  understanding  alone,  of  these  principles, 
but  upon  their  constant  application,  depends  the 
good  which  results.  The  aseptic  manner  of  hand- 
ling diseased  conditions  must  have  become  an  in- 
tegral part  of  the  man. 


CHAPTER  VI 


Wound-Healing  and  Scar-Formation 


It  was  Rudolph  Virchow  who,  in  his  work,  "Die 
Cellularpathologie,"  first  gave  a  scientific  exposition 
of  the  theory  that  every  cell  in  the  human  body 
comes  from  one  original  cell,  and  elucidated  by  his 
striking  logic,  the  manifold  significance  of  this  as- 
sumption. After  the  initial  stimulus  has  been  given 
to  the  ovum  by  fertilization,  a  progressive  cell- 
division  by  mitosis  is  inaugurated,  which  follows  an 
invariable  law.  But  the  new-formed  cells  have  not 
all  identical  characteristics.  In  the  cycle  of  cell- 
evolution,  one  of  the  primitive  functions  may  be- 
come highly  developed ;  other  functions,  which  were 
originally  common  to  all,  but  not  called  upon  by  the 
demands  of  the  organism  to  be  duly  exercised,  even- 
tually undergo  a  decadence,  or  are  entirely  lost. 

So  it  is,  for  instance,  that  in  some  of  the  cells  with 
pronounced  secretory  function,  the  function  of  re- 
production may  be  wholly  wanting.  If  that  part  of 
an  organ  which  consists  of  such  cells  is  subjected  to 
an  injury,  the  damaged  part  cannot  be  repaired  di- 
rectly by  cell-division  of  the  remaining  secretory 
cells.  A  makeshift  repair  occurs  instead,  in  which 
tissue  cells  which  still  possess  the  power  of  cell 
division,  proliferate.  By  encroaching  upon  the  de- 
fect, they  give  rise  to  a  bond  of  dissimilar  tissue 
which  constitutes  the  scar.  Thus,  in  a  healing 
wound  of  the  kidney,  not  the  secretory  portion,  but 
the  stroma,  contains  the  most  actively  growing  con- 
stituents. Cell-division  is  vigorous  among  the  cells 
of  the  connective  tissue  and  the  endothelium  of  the 
capillaries,  while  the  wounded  parenchyma  shows 

(45) 


Developing 
and 

Declining 
Cell  Functions 


Specialization 
and  Loss  of 
Reproductive 
Power 


46      Guiding  Principles  in  Surgical  Practice 


Specialization 

and 

Cell 

Growth 


very  little  tendency  to  regenerate  itself.  In  any 
single  type  of  tissue  moreover,  for  example,  glandu- 
lar epithelium,  it  is  not  the  older  cells,  mature  in 
their  particular  function,  in  which  active  cell  multi- 
plication must  be  looked  for;  but  rather,  the 
younger  forms,  which  are  still  immature,  and  not 
highly  differentiated. 

But  while  advanced  specialization  in  cells  often 
implies  a  diminished  reproductive  activity,  it  does 
not  follow  that  they  have  also  lost  their  inherent 
power  of  increasing  in  sise  by  growth.  In  fact, 
when  the  nutritional  facilities  of  the  environment 
are  adequate,  such  cells  may  undergo  an  hyper- 
trophy which  is  more  or  less  commensurate  with  the 
increased  amount  of  work  imposed  upon  them  by 
the  new  conditions.  Indeed,  it  is  the  rule,  that  they 
become  equal  to  a  greater  demand  upon  their  spe- 
cial function  by  an  increase  in  size — a  truly  com- 
pensating hypertrophy — rather  than  by  cell  multi- 
plication— hyperplasia.  If,  in  these  cases,  hyper- 
plasia were  in  accordance  with  the  natural  law, 
there  would  result  a  number  of  immature  daughter- 
cells,  which  only  after  a  certain  degree  of  develop- 
ment has  been  reached,  are  capable  of  performing 
the  elaborate  function  of  the  cells  from  which  they 
were  derived.  Initially  they  would  be  of  little  im- 
mediate worth  in  truly  compensating  for  a  func- 
tional loss.  The  direct  hypertrophy  of  highly  spe- 
cialized parenchyma  cells  therefore  becomes  neces- 
sary after  an  injury,  because  a  part  of  the  organ 
which  is  still  sound,  must  help  to  do  the  work  of 
the  whole.  Hypertrophy  of  the  parenchyma  cells 
may  occur  simultaneously  with  the  wound  healing 
process,  but  has  no  direct  relation  to  the  formation 
of  the  scar  itself. 


Guiding  Principles  in  Surgical  Practice      47 


Even  when  the  coaptation  obtained  in  a  surgical 
wound  of  the  parenchyma  is  relatively  satisfactory, 
many  cells  which  have  perished  as  a  result  of  the 
trauma  must  be  removed  during  the  healing,  and 
new  cells  take  their  place.  The  new  tissue  is  not 
the  same  as  the  old,  and  cannot  replace  it  in  func- 
tion. It  consists  largely  of  those  tissues  in  the 
wound  area  which  engender  the  greatest  repro- 
ductive activity,  irrespective  of  their  functional 
adaptation.  It  is  not  the  fittest,  but  the  most  rap- 
idly proliferating  elements,  that  close  the  defect. 
There  appears  a  complex  bridge-work  consisting 
mainly  of  connective  tissue.  Its  function  is  preemi- 
nently a  mechanical  one,  and  from  the  point  of  view 
of  secretory  or  excretory  activity,  the  cells  reveal 
little  more  than  a  primitive  character.  The  same 
law  obtaining,  the  young  scar  tissue  of  a  healed  in- 
ternal organ,  resembles  in  the  chief  points  histolog- 
ically the  scar  tissue  found  in  recently  healed 
wounds  of  the  surface  of  the  body.  Some  of  the 
parenchyma  cells  which  are  peculiar  to  a  viscus  may 
be  incorporated  in  the  scar,  and  help  to  indicate  its 
genesis.  In  the  course  of  months  or  a  year,  how- 
ever, it  consists  of  little  else  than  the  ubiquitous 
fibrous  connective  tissue,  in  the  contracting  mass  of 
which  the  existing  vessels  have  become  obliterated, 
and  the  parenchyma  cells  have  disappeared. 

The  reaction  which  takes  place  in  the  healing  of 
an  aseptic  wound  of  the  viscera,  is  comparable  to 
that  which  takes  place  in  other  wounds — 'the  differ- 
ences are  incidental  rather  than  fundamental, "  and 
depend  on  the  peculiarities  and  the  specialization  of 
the  tissues  involved.  In  practice,  there  is  hardly  a 
wound  inflicted  by  the  surgeon,  which  does  not  also 


Wound 
Healing  is 
Imperfect 


Role  of 
Connective 
Tissue   in 
Wound 
Healing 


48      Guiding  Principles  in  Surgical  Practice 

affect  the  selfsame  connective  tissue,  on  account  of 
its  universal  distribution  in  the  animal  organism  as 
a  supporting  substrat  or  sheath  for  more  highly  or- 
ganized and  more  vulnerable  structures.  Notwith- 
standing its  predominating  role  in  almost  every 
process  of  wound-healing,  it  is  of  some  surgical  im- 
portance, also  to  have  a  clear  insight  into  the  rela- 
tive regenerative  power  displayed  by  other  typical 
tissue  groups. 

^  ,       _.  In  this  study  it  is  at  once  apparent,  that  besides 

Other  Tissues    ,  ,  ■'    ,       ,,.    ,  ^^.         ' 

in  Wound  ^'^^  various  closely  allied  types  of  connective  tissue 

Healing  and  the  endothelium  of  the  capillary  blood  vessels, 
there  is  also  the  epithelium  in  general,  excepting 
that  which  is  highly  differentiated  in  function,  as  in 
the  secretory  portions  of  the  various  glands,  that  is 
to  a  greater  or  lesser  degree  capable  of  cell-multi- 
plication by  mitosis.  Hand  in  hand  with  the  con- 
nective tissue,  this  too  plays  its  part,  although  but  a 
minor  one,  in  tissue  repair. 

Likewise,  to  a  limited  extent,  the  striated  muscle 
may  produce  from  the  sarcolemma  nuclei,  new 
striated  tissue  elements.  In  the  cell  of  smooth  mus- 
cle, and  above  all,  in  the  nerve  cells,  however,  the 
generative  function  seems  completely  abolished. 
Moreover,  cells  that  have  reached  the  end  of  their 
developmental  cycle,  as  for  instance,  the  poly- 
morphnuclear  leucocytes,  belong  to  the  class  which 
has  not  longer  the  power  of  reproduction. 
Healing  of  Cartilage  injured,  or  fractured,  or  divided  in  an 
Cartilage  operation,  soon  shows  some  tendency  on  the  part 
of  its  characteristic  elements  to  repair  the  lesion; 
still,  it  is  not  infrequently  granulation  tissue  only, 
that  fills  in  the  interspace,  and  the  result  is  then  a 
purely  fibrous  scar.  In  the  case  of  a  fractured  bone, 
signs  of  indirect  cell-division  become  manifest  as 


Guiding  Principles  in  Surgical  Practice      49 


early  as  the  second  day  after  injury,  and  the  cells  of 
the  osteogenic  layer  beneath  the  periosteum,  begin 
to  proliferate  in  the  vicinity  of  the  fracture.  The 
so-called  external  callus,  which  is  often  felt  as  a 
fusiform  thickening,  owes  its  origin  conjointly  to 
the  lacerated,  and  subsequently  proliferated  con- 
nective tissue  around  the  bone,  as  well  as  to  the 
periosteum  and  the  osteogenic  layer  itself.  It  is, 
so  to  speak,  a  natural  splint,  which  shrinks  markedly 
after  firm  union  of  the  fractured  ends  has  taken 
place.  Bony  tissue  is  replaced  readily,  and  the  hope 
may  always  be  cherished  that  even  a  very  large  loss 
of  substance  will  eventually  be  made  good.  If  no 
soft  parts  become  accidentally  interposed  and  the 
periosteum  is  not  destroyed,  it  is  possible  for  an 
entire  bone,  for  example,  the  clavicle,  to  regenerate 
itself.  Strictly  speaking,  the  regeneration  of  the 
bone  is  wrought,  not  by  the  periosteum  which  is 
nothing  more  than  a  limiting  membrane  of  dense 
fibrous  connective  tissue,  but  by  the  layer  of  true 
bone-forming  cells,  the  osteogenic  layer,  which  is 
retained  beneath  it.  In  the  surgical  transplantation 
of  bone  the  periosteum  is  not  essential;  it  is  the 
osteoblasts  which  are  liberated  from  beneath  the 
periosteum  as  well  as  from  their  bony  casement, 
the  Haversian  canals,  that  have  to  do  with  the  new- 
formation  of  bone. 

As  previously  indicated,  striated  muscle  has  but 
a  limited  power  of  reproduction,  and  this,  from  the 
nuclei  in  the  sarcolemma.  The  new  striated  ele- 
ments resemble  at  first  the  immature  striated  muscle 
cells  of  the  embryo.  Their  stability  may  not  be 
greait,  they  may  undergo  pressure  atrophy  and  be 
replaced  by  connective  tissue.  In  a  wound  of  the 
abdomen,   for  instance,   where  striated  muscle  is 


Regeneration 
of   Bone 


Restoration 
of  Striated 
Muscle 


50      Guiding  Principles  in  Surgical  Practice 


Repair  of 
Smooth  Muscle 


Repair  of 
Heart  Muscle 


divided,  the  repair  is  chiefly  by  fibrous  tissue,  a  sort 
of  inscriptio  tendinae  resulting,  while  the  part  played 
by  the  scanty,  newly  developed,  muscle  elements 
when  they  do  appear,  must  in  reality  be  a  subsidiary 
one. 

The  lack  of  new  development  is  still  more  pro- 
nounced in  smooth  or  non-striated  muscle,  which  is 
dependent  entirely  on  the  connective  tissue  for  the 
equalization  of  any  loss  of  substance.  It  is  true  that 
the  smooth  muscle  may  increase  visibly  in  bulk,  but 
this  is  not  due  to  a  multiplication  of  the  muscle 
cells.  Its  basis  is  an  actual  hypertrophy  within  the 
individual  muscle-cell.  The  fact  that  smooth 
muscle,  even  when  nutritional  conditions  are  very 
favorable,  does  not  increase  in  bulk  by  hyperplasia, 
but  by  hypertrophy,  is  strikingly  illustrated  in  the 
pregnant  womb.  Here  the  existing  muscle  cells 
may  grow  to  be  as  much  as  eleven  times  as  long 
and  five  times  as  broad  as  those  in  the  non-pregnant 
womb,  while  their  number  is  not  increased. 

Heart-muscle,  in  this  respect,  may  be  said  to 
occupy  an  intermediary  position  between  the  striated 
and  smooth  variety.  Though  it  exhibits  but  little 
reproductive  power,  it  seems  probable,  that  the  en- 
larged muscle  in  a  hypertrophied  heart  is  the  result, 
not  only  of  an  increase  in  size,  but  also  an  increase 
in  number  of  the  individual  muscle-cells.  Never- 
theless the  recuperative  power  of  the  heart-muscle 
itself  is  not  conspicuous  in  wound-healing;  this  is 
apparent  in  case  of  penetrating  wounds  of  the  heart, 
which  heal  with  the  formation  of  a  fibrous  scar. 

If  nerve-tissue  of  the  cord  or  brain  undergoes 
repair  the  connective  tissue  of  the  gray  matter-— 
the  neuroglia — comes  to  the  foreground.  More- 
over, dendrites  or  neurites  which  have  been  severed, 


Guiding  Principles  in  Surgical  Practice      51 

may  regenerate  as  long  as  the  ganglion  cell  to  which 
they  belong  remains  uninjured.    Even  the  ganglion    n^^Hne  of 
cell  itself  may  undergo  a  reconstruction,  as  it  were,    Nerve 
if  the  cell-body  has  been  but  slightly  damaged,  pro-    Tissue 
viding  the  nucleus  is  still  intact.    The  specialization 
of  the  cell,  does  not  abolish  its  power  to  grow,  and 
to  undergo  hypertrophy.     It  is  only  the  power  to 
multiply  by  mitosis,  that  is  lost.    In  the  case  of  the 
peripheral  nerves,  the  restoration  of  continuity  of 
an  axis-cylinder  is  known  to  be  possible,   if   the 
defect  is  not  larger  than  five  centimetres.    At  least, 
three  to  six  months  should  be  allowed  for  this  pro- 
cess of  repair.     Larger  defects  will  also  heal,  if 
tissue   splints   are  placed   along  the  path   of   the 
excised  nerve  between  the  cut!  ends. 

Irritating  antiseptic  solutions  in  contact  with  the 
peritoneum,  provoke  a  defensive  response  in  the 
surface  endothelium,  as  well  as  in  the  connective 
tissue  substratum.    The  outcome  is  an  aseptic  local 
peritonitis — a  cellular  peritonitis — which  may  result 
in  firm  adhesions  between  two  contiguous  peritoneal 
surfaces.     Similarly,  a  gauze  drain  can  cause  ad-   Peritoneal 
hesions  of  the  peritoneal  surfaces  of  the  intestinal   Reaction  to 
loops  about  it,  so  that  a  sort  of  conduit  remains   Irritation 
when  the  gauze  is  withdrawn.     In  other  cases,  as 
in  lumbar  or  iliac  colostomy  wounds,  it  is  to  be  seen 
that  adhesions  may  form  in  less  than  twenty-four 
hours.    In  case  of  severe  anemia,  it  appears  that  the 
formation  of  adhesions  may  be  considerably  delayed. 
It  might  thus  happen  that  two  peritoneal  surfaces  of 
bowel,   which  are  held   in   contact  by  a   Murphy 
button,  may  show  no  adhesion  at  all,  even,  after 
three  days  have  elapsed.    That  a  peritoneal  coapta- 
tion may  result  in  delayed  union  of  a  bowel-wound 
in  low  states  of  the  system,  is  a  point  worth  re- 


52       Guiding  Principles  in  Surgical  Practice 


Healing 

o£  the 

Parenchyma 

of  Secreting 

Organs 


Open 
Wounds 


-memibering  in  intestinal  anastomosis  where  suture 
is  not  employed. 

True  gland-cells,  that  is,  the  cells  which  produce 
the  secretion  characteristic  of  a  gland,  are  highly 
developed  and  do  not  reproduce  their  kind  directly 
by  cell-division  of  the  mature  cell.  It  is  rather  by 
cell-division  of  more  primitive  cells,  and  their  sub- 
sequent metaplasia,  that  the  destroyed  gland-cells 
are  replaced.  In  the  case  of  the  liver,  Hess  and 
Ribbert  have  demonstrated  an  exceptionally  active 
proliferation  of  the  parenchyma-cells  after  injury. 
The  cellular  connective  tissue  in  the  healing  wound 
contains  numerous  newly  formed  bile-passages,  and 
apparently  the  immature  cells  change  into  mature 
liver  cells  with  their  highly  specialized  func- 
tion. But  even  with  this  unusual  impulse,  which  is 
evinced  initially  towards  complete  restoration  of  the 
damaged  part  of  an  organ  to  its  original  functional 
worth,  the  architecture  of  the  new  parenchyma  is 
atypical,  and  there  is  in  the  end,  as  the  recent  tissue 
grows  older,  a  much  greater  proportion  of  fibrous 
tissue,  in  which  perishing  gland-cells  are  not  re- 
placed by  new  ones. 

If  the  phenomena  of  healing  are  studied  in  a 
surface-wound,  which  has  not  been  sutured,  but  is 
left  agape  to  granulate,  it  will  be  seen  that,  under 
normal  conditions,  the  surfaces  are  red  and  clean 
and  covered  with  warty  excrescences — healthy 
granulations.  Within  three  hours  following  the 
injury,  there  is  abundant  multiplication  of  the 
nuclei  of  the  connective  tissue  cells;  and,  after  one 
or  two  days,  mitotic  division  is  apparent  in  the 
endothelial  cefls  of  the  neighboring  capillaries. 
Each  granulation  consists  of  sprouting  capillaries, 
enveloped  and  supported  in  young  connective  tissue. 


Guiding  Principles  in  Surgical  Practice       53 


When  the  balance  between  the  two  is  disturbed,  as 
when  irritating  substances  bathe  the  wound,  large, 
thin- walled  capillaries,  covered  with  a  scanty  pro- 
tecting sheath  of  connective  tissue,  appear.  These 
are  the  redundant,  readily  bleeding  granulations, 
the  exuberant  granulations  of  a  granulating  wound. 

In  the  normal  course  of  healing  of  wounds  open- 
ing upon  the  mucous  or  cutaneous  surfaces  of  the 
body,  as  the  granulations  fill  the  defect,  the  ingrow- 
ing epithelium  covers  the  raw  surface.  In  a  wound 
of  the  skin,  for  instance,  the  advent  of  the  epithelium 
can  be  followed  by  noting  the  position  of  the  thin 
blue  border  at  successive  dressings.  The  new 
epithelial  protective  layer  springs  from  the  younger 
and  more  deeply  situated  cells  of  the  epidermis,  the 
cells  of  the  Rete  Malpighii.  The  older  surface  cells 
with  cornifying  protoplasm,  and  disintegrating 
nuclei,  are  at  the  culmination  of  their  life-cycle, 
and  no  longer  possess  that  power  of  multiplying  by 
cell  division.  For  this  reason  skin  grafting  is  not 
apt  to  be  as  successful  with  the  cells  obtained  by 
simply  scraping  the  surface,  as  when  a  thin  epi- 
dermal graft  is  taken  close  to  the  tops  of  the 
papillae  by  means  of  a  sharp  razor. 

From  what  has  been  pointed  out,  it  is  clear,  that 
any  production  of  scar  tissue  in  excess  of  what  is 
absolutely  necessary  for  the  mechanical  purpose 
of  holding  the  severed  structures  together,  is  un- 
desirable because  in  it  is  practically  never  repro- 
duced the  elaborate  tissue  of  the  parts  which  it 
unites.  In  this  connection,  the  question  might  arise, 
if  the  excessive  scar-formation  which  sometimes 
follows  the  closure  of  an  abdominal  wound,  is  a 
prophylactic  or  predisposing  factor  in  the  occur- 
rence  of   post-operative   hernia.     In   the   vertical 


Exhuberant 
Granulations 


Epithelial- 
ization 


Massive 
Scars 


Elastic 


54      Guiding  Principles  in  Surgical  Practice 

median  incision  for  celiotomy,  the  resultant  scar  is 
vertical.  It  has  none  of  the  elastic  fibres,  and  none 
of  the  elasticity  of  Scarpa's  fascia  which  it  traverses, 
and  offers  a  definite  resistance  to  every  excursion 
of  the  abdominal  wall,  interfering  directly  with  its 
normal  mechanics.  When,  at  last,  it  yields  to  the 
strain,  having  no  elasticity,  it  yields  indefinitely, 
and  the  hernial  protrusion  so  common  after  this 
incision,  is  imminent.  An  excessive  scar  is  a  hind- 
rance rather  than  an  advantage,  and  while  the  quan- 
tity of  the  abnormal  tissue  is  increased,  its  quality, 
its  elastic  fibre  content,  is  not  improved. 

The  fact  that,  in  general,  elastic  fibre  is  but  slowly 
'piljres  ^^^  imperfectly  regenerated  in  a  cicatrix,  merits 
due  consideration  in  the  surgery  of  the  various 
structures  of  connective  tissue  origin.  Tendons, 
which  are  rigid,  inelastic  connective  tissue  forma- 
tions, and  serve  to  anchor  the  contracting  muscle, 
are  comparatively  devoid  of  elastic  fibres,  and  their 
reconstruction  after  an  injury  is  functionally  more 
or  less  satisfactory.  In  the  subcutaneous  section  of 
the  tendo  Achilles,  a  gap  of  two  inches  following 
the  correction  of  a  pes  equino-varus,  need  ordin- 
arily cause  no  solicitude.  The  healing  of  fasciae 
also,  because  they  are  of  connective  tissue  origin, 
may  be  expected  to  take  place  rapidly ;  still,  how  well 
its  functional  worth  will  be  restored  in  each  case, 
really  depends  on  how  much  elastic  fibre  originally 
enters  into  the  make-up  of  the  particular  structure. 
Scar  tissue  has  less  stability  than  the  fibrous  tissue 
which  appears  in  the  body  under  normal  physio- 
logical conditions.  In  addition,  it  is  decidedly  slug- 
gish in  developing  elastic  fibres  in  its  matrix. 
Scarcely  any  can  be  detected  before  three  weeks 
(Ziegler;  Adami).     They  are  to  be  found  chiefly 


Guiding  Principles  in  Surgical  Practice      55 


in  the  periphery  of  the  scar,  and  occur  as  very  fine 
fihrils.  It  is  clear  therefore,  that  physically,  scar 
tissue  cannot  at  all  supplant  a  fascial  structure 
which  is  rich  in  elastic  fibres.  On  the  other  hand, 
it  may  replace  fascial  defects  more  adequately 
when  the  fascia  is  inelastic,  particularly  when  it  is 
in  an  anatomic  location  where  it  is  not  subjected  to 
any  great  strain.  Again,  ligaments  which,  as  a  rule, 
are  inextensile  bands  of  fibrous  tissue,  and  serve 
the  purpose  of  binding  bones  together,  may  become 
relatively  inefficient,  when  they  are  divided  in  an 
operation,  or  accidentally  torn.  Although ,  they 
heal  promptly  with  the  formation  of  a  seam  of  new 
fiibrous  tissue,  this  bond  of  union  is  of  inferior 
quality  and  tensile  strength. 

Furthermore  some  ligaments,  such  as  the  liga- 
menta  subflava,  which  connect  the  arches  of  the 
vertebrae  with  each  other,  consist  almost  exclusively 
of  elastic  tissue.  Here  the  elasticity  of  the  ligament, 
may  be  said  to  act  as  a  substitute  for  muscular 
power.  Similarly  the  inferior  calcaneo-navicular 
ligament — the  so-called  "spring"  ligament — which 
is  the  prime  factor  in  maintaining  the  bony  arch  of 
the  foot,  and  gives  it  its  elasticity,  owes  this  quality 
to  a  considerable  amount  of  elastic  fibres.  The 
reason,  therefore,  for  preserving  such  structures  as 
these  intact  during  operative  measures,  as  well  as 
their  imperfect  healing  after  injury,  is  apparent. 

It  is  the  rule,  in  the  animal  organism,  that  elastic 
fibres  occur  in  abundance  in  those  structures  of 
connective  tissue  origin  which  are  physiologically 
subject  to  exercise.  Thus,  the  loose,  yielding  peri- 
mysium externum  of  a  muscle,  that  is,  the  external 
connective  tissue  sheath  of  it,  contains  numerous 
elastic  fibres;  while  the  rigid  tendon,  which  is  also 


Exercise 
and    the 
Role  of  Elastic 
Fibres 


56      Guiding  Principles  in  Surgical  Practice 

a  connective  tissue  derivative,  is  characterized  by 
.  the  absence  of  elastic  elements.  Again,  while  in  the 
main,  the  fascial  sheath  of  a  muscle  abounds  in 
elastic  fibres,  the  fascial  planes  to  which  the  self- 
same muscle  is  attached,  may  show  them  to  be  but 
few  and  far  between. 

Histologically,  normal  fibrillar  connective  tissue 
practically  always  contains  some  elastic  fibres,  al- 
though the  number  may  be  very  small.  Appearing 
as  extremely  thin  fibrils  in  the  matrix  they  broaden 
with  advancing  growth.  They  may  form  a  complex 
meshwork  of  fibres,  or,  as  in  the  endocardium,  for 
example,  by  their  fusion  there  results  a  fenestrated 
elastic  layer  or  membrane.  It  is  only  when  the 
elastic  fibres  are  present  in  predominating  quantity 
over  the  connective  tissue  bundles,  and  the  me- 
chanics of  the  arrangement  of  the  connective  tissue 
strands  allows  it,  that  they  can  impart  to  it  their 
physical  property  of  elasticity. 

From  another  than  the  purely  cosmetic  point  of 
view,  incisions  involving  the  skin  and  the  resulting 
scar,  are  of  interest  to  the  surgeon.  As  far  as  this 
Elastic  Fibrils  is  possible,  the  incision  is  made  along  the  line  in- 
m  the  Skin  dicated  by  a  natural  fold.  In  this  situation  the  fine 
scar  of  a  healed  wound,  besides  receding  from  view, 
is  subjected  to  only  occasional,  but  not  to  constant 
stretching,  and  the  new  tissue  has  ample  time,  in  the 
intervals,  to  recontract  and  to  regain  its  tone.  On 
the  abdomen  vertical  incisions,  even  after  an  almost 
scarless  primary  union,  tend  to  widen  gradually. 
Subsequently,  as  in  all  scars,  the  soft,  pink  vascula- 
rised  tissue  becomes  white,  hard  and  atrophic,  and  in 
the  course  of  a  few  years,  a  scar  which  was  at  first 
faintly  linear,  may  be  a  fourth  to  a  half  inch  wide, 
and  considerably  attenuated. 


Guiding  Principles  in  Surgical  Practice       57 

Although  the  condition  of  the  underlying  struc- 
tures may  prevent,  at  this  time,  any  actual  hernial 
protrusion,  the  partial  inefficiency  of  the  repair 
cannot  be  questioned.  Stretching  occurs,  no  matter 
how  nicely  the  skin  has  been  closed,  whether  it  be 
with  Michel's  clamps,  or  adhesive  strips,  or  the 
finest  cuticular  or  subcuticular  suture.  The  real 
reason  for  an  inadequacy  in  the  healing  of  a  cutane- 
ous wound  is,  in  all  likelihood,  to  be  found  in  the 
deficiency  in  elastic  elements  in  its  scar.  It  is  to 
be  recalled,  that  the  normal  skin  is  well  supplied 
with  these.  From  the  subcutaneous  connective 
tissue  numerous  thick  elastic  fibres  radiate  into  the 
corium,  and  reduced  in  size  terminate  largely  in  a 
fine  meshwork  which  lies  just  beneath  the  epidermis. 
If  the  limit  of  elasticity  has  been  exceeded  in  the 
skin,  numerous  irregular,  pinkish  furrows  appear 
on  the  surface,  to  indicate  the  lines  along  which  the 
delicate  corium  has  been  overstretched  and  rup- 
tured. Here,  instead  of  the  complex  plexus  of 
elastic  fibres,  isolated  fibres  that  have  remained  in- 
tact, in  small  numbers,  and  running  a  parallel 
course,  can  be  traced  across  the  attenuated  zone. 
Thus  the  undue  distention  of  the  abdominal  wall 
in  pregnancy,  results  in  the  appearance  of  the 
striae  gravidarum  in  the  integument.  In  old  age, 
too,  the  skin  loses  its  elasticity;  a  physiological 
degeneration  of  the  elastic  fibres,  keeps  pace  with 
the  other  processes  of  involution  incident  upon 
senile  atrophy.  Few  Elastic 

Old  scar  tissue  bleeds  but  little,  or  not  at  all,  when    Fibrils  in  Old 
incised,  because  its  blood  vessels  have  disappeared.      ^^^^ 
It  has  but  little  vitality,  and  shows  only  slight  re- 
sistance  to   the    destructive   action   of    pathogenic 
germs.    Thus,  it  may  happen  that  suppuration  fol- 


58      Guiding  Principles  in  Surgical  Practice 

lows  the  line  of  a  previously  existing  scar,  to  reach 
the  surface,  because  the  normal  skin  about  it,  with 
its  elastic  framework  and  vigorous  cells,  proves  to 
Should  a  Young  ^^  ^  ^^^.^  efficient  barrier  to  its  progress. 

E        ised?       '^^^  salient  question.  Does  exercise  help  the  de- 
velopment of  elastic  fibre  in  the  scar  following  an 
operation  ?  has  not  been  finally  answered.  It  is  only 
when  the  scar  is  still  recent,  that  it  is  soft  and 
pliable,  and  possesses  a  small  degree  of  resiliency. 
It  is  at  this  time,  if  at  all,  that  the  development  of 
the  elastic  fibre  must  be  encouraged  by  proper  ex- 
ercise of  the  part.    Nevertheless,  if  the  scar  is  put 
to  a  strain  before  it  has  time  to  acquire  sufficient 
stability,  it  will  yield  and  broaden  by  stretching.    A 
laparotomy    scar,    one    week    after    operation,    is 
usually  too  young  to  sustain  the  weight  which  is 
brought  to  bear  upon  it  during  bodily  movements. 
The  average  time  required  to  obtain  union  which  is 
sufficiently  secure  to  allow  the  patient  to  be  out  of 
bed,  is  from  twelve  to  fourteen  days.     During  the 
week  of  lounging,  which  follows  the  stay  at  the 
hospital,   or  perhaps  an  additional  week,   a  firm, 
correctly  applied  bandage  may  give  support  to  the 
wound.     If  the  hypothesis  is  tenable,  that  the  re- 
generation  of   elastic   fibre  can  be  stimulated  by 
training  the  scar,  then  the  wearing  of  trusses  or 
belts  after  operation  is  not  logical,  and  graduated 
exercise  ought  to  begin  after  the  third  week,  that  is, 
coincident  with  the  time  when  the  elastic  fibrils 
begin  to  appear.    However,  this  may  be,  there  is  a 
pretty   general    disinclination   among   surgeons  to 
endorse  the'  wearing  of  mechanical  appliances,  for 
long  periods  after  an  operation,  except  in  the  flabby 
patient  who  possesses  but  little  physical  tone. 


CHAPTER  VII 


Aseptic  Suture  Material 


Sutures 
Avoidable 
in  the  Skin 


There  is  a  certain,  inevitable  scar- formation  going 
on  in  every  wound  during  the  healing  of  it,  no 
matter  how  nicely  apposed  the  divided  tissue  may 
be.     The  cicatrization   is  materially   increased   by 
the  presence  of  a  foreign  body,  or  the  action  of    Suture 
chemical  irritants.    All  suture  materials  are  foreign    Materials  are 
bodies,   and   all   antiseptic   solutions   are   chemical    Foreign 
irritants.     The  exclusion  of  irritant  solutions  is  a    Bodies 
simple  matter  and  is  practicable,  but  not  so  the 
abolition  of  the  suture. 

In  a  wound  zvhich  involves  only  the  surface,  a 
skin-wound  for  example,  the  actual  penetration  of 
the  tissues,  and  the  lodgment  of  sutures  in  them 
can  frequently  be  avoided  by  the  use  of  tiny  clamps 
of  metal,  Michel's  clamps,  or  sterile  zinc  oxide 
adhesive  strips.  It  is  thus  possible,  in  a  limited 
number  of  cases,  to  obviate  altogether  the  introduc- 
tion of  a  foreign  material  into  the  tissues.  But, 
when  the  deeper  layers  of  a  wound  must  be  brought 
into  apposition,  the  use  of  the  suture  can  scarcely 
be  circumvented. 

Coaptation   is    needed,    until    the    newly-formed    ^fter  Healing, 
tissue  has  sufficient  stability  to  retain  the  severed     the  Sutures  are 
parts  in  position.    After  that,  solution  of  continuity     Redundant 
and  absorption  of  the  suture  by  the  tissues  which 
it  traverses,  is  looked  for,  unless  the  material  is  not 
absorbable,  and  must  either  continue  to  remain  as 
a  foreign  body,  or  else  be  removed  by  extraction. 
But  extraction  of  sutures  from  the  deeper  layers  is 

(59) 


60       Guiding  Principles  in  Surgical  Practice 


Qualities  of 

Suture 

Material 


Catgut, 

Histologically 

and 

Chemically 


Catgut 
Digestion 


■  impracticable,  and  again,  it  is  obviously  objection- 
alble  to  leave  sutures  that  cannot  be  absorbed. 

A  solution  of  the  problem,  was  given  long  ago 
(1870),  when  it  occurred  to  Sir  Astley  Cooper,  that 
violin  strings  might  also  be  used  in  surgery.  Since 
then,  the  preparation  of  aseptic,  absorbable  sutures 
of  catgut,  has  been  the  subject  of  considerable 
study.  The  prime  qualities  of  suture  material,  as 
it  is  required  in  plastic  surgery,  are : 

(a)  Sterility. 

(b)  Definite  and  measured  absorbability. 

(c)  Fineness  with  adequate  tensile  strength. 

(d)  Pliability. 

Even  at  the  present  day  there  is  no  vegetable 
fibre,  animal  or  synthetic  product,  which  answers  all 
these  requirements  quite  as  well,  as  the  suture  pre- 
pared from  catgut.  Catgut,  as  its  name  does  not 
imply,  is  usually  obtained  from  sheep's  gut.  After 
the  process  of  preparation,  the  serous,  muscular, 
and  mucous  coats  are  lost,  and  there  remains  little 
more  than  the  submucosa,  consisting  of  a  stratum 
of  loose  connective  tissue  with  a  few  elastic  fibres. 
In  the  main,  then,  the  catgut  of  commerce  consists 
of  connective  tissue.  From  the  chemical  standpoint, 
excluding  the  elastic  'fibres,  almost  its  entire  mass 
is  collagen.  Collagen  is  a  substance  which,  with  or 
without  the  aid  of  enzymes,  furnished  by  poly- 
morphnuclear  leucocytes,  and  probably  various 
other  tissue  cells,  becomes  hydrated,.  and  is  first 
converted  into  the  water-soluble  gelatin.  In  this 
form  it  yields  more  easily  to  enzymotic  action,  and 
undergoes  further  digestion,  apparently  resolving 
into  albumoses  and  peptones,  until  it  disappears 
completely  and  is  absorbed. 


Guiding  Principles  in  Surgical  Practice      61 


A  piece  of  aseptic  catgut  imbedded  in  living  tissue, 
calls  forth  a  definite  tissue  reaction,  which  presents 
two  phases.  In  the  one,  the  cell  activity  is  aimed 
at  removing  the  foreign  body  which  is  lodged  in  the 
tissues ;  in  the  other,  the  forces  at  work  are  directed 
towards  effecting  a  replacement  of  the  damaged 
tissue  in  the  path  of  the  suture.  But  these  two 
phases  of  cell-activity  are  revealed  as  well,  in  every 
healing  wound.  There,  too,  the  destroyed  tissue 
undergoes  catalysis  and  is  removed,  while,  at  the 
same  time,  reconstructive  processes  are  going  on. 

The  structural  changes  which  take  place  in  cat- 
gut when  it  is  imbedded  in  living  tissue,  have  been 
followed  microscopically  by  animal  experiments. 
With  the  imbibition  of  water  from  the  tissue-plasma 
which  bathes  the  suture,  the  piece  of  catgut  begins 
to  swell  and  untwist,  and  becomes  loose  in  texture. 
The  ameba-like  polymorphnuclear  leucocytes,  which 
at  the  beginning  are  present  in  considerable  num- 
bers, find  their  way  into  the  interstices  of  the  suture, 
while  the  cells  of  the  granulating  tissue  crowd 
closely  around  it.  Under  the  influence  of  the 
moisture  and  the  enzymotic  action  of  these  cells, 
the  dissolution  of  the  catgut  fibre  is  started.  At 
first  there  is,  what  might  be  called,  a  fragmentation 
of  the  catgut,  and  then  a  disappearance  of  the 
particles. 

The  inauguration  of  the  whole  process  of  catgut 
solution  probably  depends  primarily  on  the  absorp- 
tion of  tissue- water.  By  subjecting  the  gut  to  the 
action  of  certain  chemical  substances,  the  absorption 
of  water  can  be  retarded,  and  consequently  its  re- 
sistence  to  dissolution  by  the  body  tissues,  con- 
siderably increased.     Thus,  catgut  strands  of  more 


Tissue 

Reaction 

Towards 

Imbedded 

Catgut 


Microscopic 

Changes 

During 

Catgut 

Absorption 


Moisture 
Starts  the 
Process 


62      Guiding  Principles  in  Surgical  Practice 


Designating 

Catgut 

Resistance 


Meaning  of 

these  Terms 

in  the 

Human 

Subject 


or  less  definite  and  known  grades  of  resistance  can 
be  prepared. 

To  indicate  the  degree  of  resistance  to  absorption, 
it  has  been  the  custom  of  the  manufacturers,  with  a 
few  exceptions,  to  designate  the  suture  material  by 
the  number  of  days  it  requires  until  pronounced 
signs  of  catgut  dissolution  are  to  be  seen  when  it 
is  imbedded  experimentally  in  the  thigh  muscle  of 
a  rabbit.  Thus,  the  term  "forty-day"  chromic  cat- 
gut, for  instance,  is  meant  to  imply  that  the  par- 
ticular strand  has  been  treated  with  chromic  acid 
to  such  a  measure,  that  it  is  able  to  withstand 
absorption  in  the  thigh  muscle  of  the  test  animal 
for  an  average  period  of  forty  days.  Thereafter, 
the  rapidly  disintegrating  suture,  can  no  longer 
properly  be  said  to  have  any  retentive  value.  With 
these  facts  in  mind,  the  terms  "10,  20,  30,  40,  60  or 
80-day"  catgut,  ought  not  to  be  misleading;  they 
have,  in  the  human  subject  only  a  relative,  not  an 
absolute  value. 

It  is  apparent,  that  the  time  required  for  absorp- 
tion in  the  human  muscle  need  not  be  exactly  the 
same  as  that  in  the  test  animal.  One's  judgment  as 
to  how  long  a  piece  of  catgut  of  given  resistance 
shall  last  in  the  human  tissue,  depends  on  a  number 
of  factors  which  influence  the  rate  of  absorption. 
Besides  considering  the  difference  between  human 
muscle  and  animal  muscle,  it  must  be  remembered 
that  not  only  muscle,  but  various  other  tissues  are 
repaired  by  suture,  and  each  tissue  exerts  its  own 
peculiar  catalytic  action.  The  specific  tissue  in- 
fluence upon  catgut  is  still  more  detailed  than  this, 
for  not  only  the  different  tissues  in  the  same  indi- 
vidual, but  also  the  same  tissue  in  different  indi- 
viduals, have  this   solvent  power  to  a  somewhat 


Guiding  Principles  in  Surgical  Practice      63 


unequal  degree.  In  the  case  of  a  continuous  suture 
of  the  skin,  it  can  sometimes  be  observed  that  even 
the  various  portions  of  the  same  suture  are  not 
always  absorbed  with  the  same  rapidity.  In  the 
semilunar  hypogastric  incision,  a  slight  difference 
in  absorbability  may  occasionally  be  discovered  at 
the  ends  of  the  incision  as  compared  with  its  middle 
portion  which  invades  the  zone  of  the  suprapubic 
hair  follicles.  When  segments  of  the  suture  remain 
exposed,  as  in  skin  and  mucous  membrane  repair, 
the  amount  of  surface  moisture  may  have  much  to 
do  with  premature  dissolution.  Wet  dressings, 
douches,  discharges,  wound  or  gland  secretions, 
sweating,  all  may  help  to  macerate  the  catgut,  and 
shorten  the  period  of  its  usefulness. 

Clinically,  catgut  behavior  can  most  conveniently 
be  studied  in  surface  sutures.  In  order  to  eliminate 
outside  factors  which  may  complicate  the  observa- 
tion, the  wound  must  first  of  all,  be  kept  dry.  In 
the  dry,  clean  wound  the  solution  of  continuity  of 
the  part  of  the  suture  which  is  imbedded  in  the 
tissue  is  indicated  by  the  falling  off  of  the  knots  on 
the  surface.  When  this  has  happened,  the  con- 
tinuity of  the  suture  being  broken,  the  material  can 
no  longer  serve  the  purpose  of  holding  the  tissues 
together,  and  with  this,  its  serviceability  ends. 
Thus,  it  will  be  found,  that  a  piece  of  fine  "forty- 
day"  chromic  catgut  may  last  five  to  seven  days, 
and  occasionally  even  twelve  days  or  more,  when 
employed  as  a  skin  suture.  The  variation  in  time 
required  in  similar  locations  may  therefore  be  as 
much  as  one  week.  The  same  technic  may  have 
been  resorted  to  in  each  instance,  and  still  such 
marked  latitude  as  this  is  observed  for  material  of 


The  Useful 
Period  o£ 
Catgut   in 
Human 
Tissue 


64       Guiding  Principles  in  Surgical  Practice 

apparently    the    same    resistance.      Obviously    the 

reason  is  to  be  sought  in  the  hitherto  but  little 

studied  processes  of  tissue  digestion.     In  the  one 

Tissue  Water  case    the    enzymotic    action    unfolds    itself    more 

Essential  for  speedily,  than  in  the  other.     This  in  turn  is  made 

nzyme  pQggj^^ig  ]-,y  ^j^g  presence  of  sufficient  water  in  the 
tissue  in  which  the  suture  lies  imbedded.  If  there 
were,  besides  the  living  cells,  no  fluid  in  the  inter- 
cellular spaces,  no  tissue-plasma,  then  the  digestion 
of  catgut  in  the  tissues  would  seem  quite  impossible. 
Water  is  necessary  for  catgut  digestion  in  the  tis- 
sues, just  as  it  is  requisite  in  the  digestive  processes 
in  the  alimentary  canal.  In  both  cases  the  action  is 
fundamentally  one  of  progressive  hydration.  Water 
is  taken  up  into  the  dissociating  molecule  of  colla- 
gen, and  finally  assimilable  proteoses  and  peptones 
result.  So  it  is  that  catgut  disappears  more  rapidly 
in  the  succulent  derma  of  the  young  man,  than  in 
the  desiccated  skin  of  the  aged. 

It  has  been  observed  that  in  the  course  of  catgut 

disintegration   small   fragments   may  be  taken   up 

into  the  bodies  of  the  polymorphnuclear  leucocytes. 

It  would  seem  likely  that  the  same  principles  are 

X  race  u  ar   ^^^^^   j^gj.g    jj^   intracellular   catgut    digestion,    that 

Intracellular  g^overn  extracellular  catgut  digestion,     i  he  moisture 

Catgut   supplied  by  the  cytolymph,  makes  it  possible  for  the 
Digestion   enzyme  produced  within  these  cells  tt>  exert  their 
solvent  influence. 

In  a  measure,  the  time  of  catgut  absorption  is 
also  affected  by  the  thickness  of  the  strand.  It 
necessarily  takgs  longer  to  bring  about  solution  of 
continuity  in  a  thick,  than  it  does  in  a  fine  suture. 
But  the  selection  of  bulky  sutures  is  not  in  accord 
with  the  modern  tendency  towards  finer  technic. 
It  is  better  to  choose  thin  sutures,  by  which  the  most 


Guiding  Principles  in  Surgical  Practice      65 


accurate  apposition  with  the  smallest  amount  of 
damage  to  the  tissues,  is  obtainable.  Instead  of 
increasing  the  size  to  obtain  the  desired  durability, 
the  chromici.'^ation  of  the  finer  strands  should  be 
increased.  It  is  only  in  order  to  get  sufficient  ten- 
sile strength  that  larger  sizes  may  be  introduced, 
but  never  to  increase  the  resistance.  If  the  material 
is  handled  with  the  gentleness  which  the  delicate 
make-up  of  the  tissues  demands,  sutures  which  are 
coarser  than  No.  1  or  No.  2  will  seldom  be  required 
in  the  course  of  major  operations.  In  other  words, 
the  finer  sutures  are  to  be  generally  preferred,  not- 
withstanding that  they  may  have  to  be  chemically 
modified  in  order  to  become  sufficiently  lasting. 

It  is  not  tissue  constriction  and  strangulation,  but 
gentle  tissue  coaptation  or  apposition  until  the  young 
scar  is  sufficiently  formed  to  support  the  parts  which 
it  binds  together,  that  is  the  end  and  aim  of  the 
reparative  suture.  The  use,  in  many  instances,  of 
finer  suture  material  than  has  been  customary,  will 
not  appear  an  unnecessary  refinement  when  besides 
the  gross  anatomy  of  the  structures  their  histology 
is  considered. 

Thus,  a  fine  catgut  filament,  000  in  size,  or  more 
accurately,  31-32  Brown  &  Sharp  standard  wire 
gauge,  may  well  replace  coarser  material,  for  whip- 
ping the  mesenteriolum  over  the  invaginated  stump 
of  the  appendix,  for  suture  in  all  circumcisions  of 
both  male  and  female  subjects,  for  primary  coapta- 
tion sutures  in  the  bladder,  for  repair  of  the  ovary 
after  partial  excision,  for  skin  stitching  where  re- 
moval of  the  suture  is  to  be  avoided,  for  buried 
sutures  or  mucous  membrane  sutures  when  required 
in  dainty  plastic  operations  on  the  face  or  elsewhere. 
Originally  (1907),  I  had  this  catgut  prepared  for 


Choice  of 
Thin  Sutures 


Chromic 
Filament 


,  66      Guiding  Principles  in  Surgical  Practice 

me  by  the  manufacturers  (Van  Horn)  for  ovarian 
suture,  because  fine-bodied  needles  such  as  are  best 
fitted  for  this  repair  would  not  admit  the  coarser 
strands  which  are  commonly  in  use.  Indeed,  after- 
bleeding  from  the  stroma  or  hilum  is  less  likely  to 
occur  with  this  technic,  than  when  coarser  material 
is  used,  because  there  is  less  laceration  of  the  friable 
tissue.  In  its  most  generally  useful  form,  000  cat- 
gut ought  to  be  chromicized  to  "forty-day"  resist- 
ance. Occasionally,  however,  as  in  the  mucous 
membrane  of  the  nose  or  rectum,  "sixty-day" 
chromicization  is  necessary.  Filaments  so  fine  as 
those  represented  by  000,  it  may  be  argued,  require 
too  much  caution  in  handling,  but  this  objection 
must  grow  weaker  as  the  conviction  grows  stronger 
that  the  tensile  strength  is  quite  sufficient  for  the 
purpose  for  which  it  is  intended — the  coaptation 
and  not  the  compression  or  constriction  of  the 
Aseptic   not     (jgijcate  living  fabric  which  it  mends. 

Cateut  Chromicized,  unlike  iodized  catgut,  is  so  prepared 
that  it  contains  no  chromic  acid  which  is  not  in 
stable  chemical  combination  with  its  collagen.  There 
is  no  free  chromic  acid  or  chromate  in  solution  in 
the  medium  in  which  the  strands  are  preserved. 
However,  after  a  definite  number  of  days,  when  the 
chromic  catgut  is  converted  into  soluble  bodies  in 
the  tissues,  it  is  true  that  the  chromic  acid  radical 
must  again  be  liberated.  But  at  this  time,  the  more 
active  healing  processes  are  ended,  and  the  traces 
of  the  foreign  chemical  no  longer  so  readily  disturb 
the  chemistr)rof  the  young  and  susceptible  growing 
cells. 

In  a  general  way,  it  may  be  said  that  for  the 
usual  purposes  of  suture,  catgut  of  "forty-day" 
resistance  should  be  employed.  This  insures  stability 


Guiding  Principles  in  Surgical  Practice      67 


of  the  suture-line  for  a  minimum  period  of  about 
seven  days,  which  is  usually  sufficient  for  wound 
healing.  Only  in  certain  localities,  where  the  sutures 
are  exposed  to  maceration  from  stagnating  secre- 
tion, or  when  the  structures  are  edematous  as  the 
perineum  after  childbirth,  a  bit  of  chromic  catgut 
of  "forty-day"  resistance  may  undergo  solution  of 
continuity  prematurely,  that  is,  perhaps  as  early  as 
the  fifth  day  or  even  sooner  after  its  insertion. 
Where  this  difficulty  is  anticipated,  strands  of  "sixty" 
or  even  "eighty-day"  resistance  can  be  used,  but  this 
is  rarely  necessary.  Where  there  exists  doubt  about 
the  necessary  resistance  of  a  suture  which  involves 
the  surface,  it  is  better  to  choose  inabsorbable  ma- 
terial, such  as  silk-worm  gut  of  the  appropriate 
strength.  When  the  suture  involving  the  surface 
cannot  be  kept  dry,  silk-worm  gut  has  many  advan- 
tages over  catgut.  It  is  not  only  insoluble  in  dis- 
charge or  secretion,  but,  unlike  the  collagen  of  cat- 
gut, offers  no  favorable  medium  for  bacterial 
growth.  Apposition  can  be  maintained  as  long  as 
even  the  most  exceptional  conditions  may  require, 
and  when  the  union  is  secure,  the  silk-worm  suture 
is  easily  extracted.  When  the  stitch  includes  the 
skin,  silk-worm  gut  is  also  preferable  to  silk  or  linen. 
Because  of  its  lack  of  capillarity,  it  does  not,  as  these 
do,  imbibe  bacterial  fluids  which  bathe  the  surface, 
and  conduct  infection  along  the  path  of  the  stitch. 
There  is  ample  scope  to  satisfy  the  various  demands 
upon  its  tensile  strength,  from  the  coarser  strands 
for  a  torn  perineum,  to  the  finest  filament  (XX 
Special,  Van  Horn),  which  is  suitable  for  finer 
plastic  surgery.  It  has  the  further  advantage  that  it 
can  be  quickly  sterilized  by  boiling  in  plain,  or  even 
in  slightly  alkalinized  water. 


Indications 

for 

Absorbable 

and 

Inabsorbable 

Sutures 


68       Guiding  Principles  in  Surgical  Practice 


Linen   Thread 

for    Hollow 

Organs 


Objections  to 

Catgut    for 

Skin   Repair 


Silk  and 
Linen 

Silk-worm 
Gut 


Skin   Clamps 


In  the  surgery  of  hollow  organs  such  as  the  heart, 
blood  vessels,  stomach,  bowel,  bladder,  where 
structures  have  to  be  repaired  which  are  under 
constant  or  varying  tension,  it  is  unquestionably 
safer  to  adhere  to  the  use  of  inabsorbable  sutures 
in  place  of  catgut,  notwithstanding  the  fact  that  such 
sutures  cannot  be  extracted  and  must  remain  as 
foreign  bodies  in  the  tissues  which  they  unite.  Such 
an  inabsorbable  thread  also  finds  its  place  in  the 
purse-string  closure  of  the  caecum  after  appendi- 
cectomy,  or  of  the  peritoneal  sac  of  a  hernia.  Linen 
thread  has  the  great  advantage  over  silk  that  it  can 
be  boiled  in  plain  as  well  as  slightly  alkalinized 
water  with  relative  impunity,  while  silk  more  rapidly 
loses  its  tensile  strength. 

The  cardinal  objection  to  the  employment  of  cat- 
gut suture  on  the  surface  of  the  body,  is  its  great 
liability  to  become  infected,  and  to  transmit  an 
infection  along  the  stitch-canal  to  deeper  planes. 
This  will  not  appear  startling,  when  it  is  recalled 
that  the  collagen  content  of  the  catgut  suture  easily 
becomes,  in  the  presence  of  moisture,  a  good  soil 
for  bacterial  growth.  Silk  or  unimpregnated  linen 
thread  have  the  common  disadvantage  of  capillarity, 
which  also  means  imbibition  of  moisture,  and  con- 
duction of  germ-growth.  Silk-worm  gut  has  none 
of  these  properties,  and  is  therefore  a  very  satis- 
factory suture  material  for  the  skin.  Even  when  a 
surface  is  naturally  apt  to  be  contaminated  on 
account  of  the  location  of  the  wound,  or  where  it  is 
bathed  in  discharge,  there  is  but  little  tendency  to 
the  development  of  stitch  infection.  Metal  clamps, 
such  as  Michel's  clamps,  eliminate  the  trouble  from 
stitch  infection,  because  they  make  possible  skin 
closure  by  clamping  without  perforation.    They  are 


Guiding  Principles  in  Surgical  Practice      69 


suitable  in  aseptic  laparotomies;  particularly  in 
point,  in  the  hairy  zone  of  the  pubes  after  the  semi- 
lunar hypogastric  incision.  To  avoid  decubitus  they 
should  not  be  applied  too  firmly.  Nevertheless, 
although  correctly  applied,  they  not  infrequently 
occasion  slight  pain  in  the  region  of  the  wound. 
They  should  be  removed  after  five  days,  a  few  strips 
of  sterile  adhesive  plaster  continuing  to  support  the 
young  scar  for  a  few  weeks.  There  need  be  no  fear 
that  the  clamps  will  be  dislodged  by  the  patient, 
even  if  used  on  the  abdomen  to  close  incisions  eight 
or  more  inches  long. 

Occasionally,  as  for  instance,  in  some  incised 
wounds  of  the  face  in  children,  in  order  to  escape 
stitching,  or  after  abdominal  sections  in  place  of 
skin  clamps,  sterile  zinc  oxide  adhesive  strips  can 
be  used.  The  secret  of  success  in  employing  them, 
lies  in  the  thorough  removal  of  the  fatty  secretion. 
From  a  cosmetic  standpoint  the  result  obtained  by 
either  the  clamp  or  the  adhesive  strip  method,  per- 
haps surpasses  that  obtainable  by  any  suture 
method. 

In  contradistinction  to  most  other  tissues,  in  the 
repair  of  osseous  tissue,  the  physical  conditions  are 
such  that  absorbable  suture  is  commonly  inadequate. 
Only  a  few  of  the  smaller  bones  may  be  an  ex- 
ception. When  proper  coaptation  and  fixation  is 
not  obtainable  by  reduction,  traction,  external  splint- 
ing of  a  long  bone,  silver  wire,  Lane's  plates, 
cortical  or  intramedullary  splints  of  living  bone,  all 
may  have  their  place. 

At  the  present  time,  the  most  satisfactory  way  of 
supplying  sterilized,  plain,  as  well  as  chemically 
modified  catgut,  is  in  sealed  glass  tubes.  Since  it 
is  in  this  case  necessary  to  rely  on  the  efficiency  of 


Coaptation 
with  Adhesive 
Strips 


Methods   of 
Uniting  Bone 


70      Guiding  Principles  in  Surgical  Practice 


Guarantee  of 

Catgut 

Sterility 


Catgut   is   Dry 

Sterilized  and 

Preserved    in 

Sealed 

Tubes 


the  sterilization  of  the  catgut  by  the  manufacturers, 
many  methods  for  its  extemporaneous  preparation 
have  been  suggested.  While  this  tendency  must 
appeal  to  one  who  is  solicitous  about  the  asepsis, 
and  desirous  to  have  under  his  control  or  super- 
vision the  sterilization  of  the  catgut  which  he  needs 
at  his  operations,  it  must  be  granted,  on  the  other 
hand,  that  the  usual  complaint  about  catgut  ster- 
ility is  not  well  founded.  For  example,  from  the 
record  of  one  series  of  120  cases  in  which  catgut, 
plain  and  chromic,  from  one  of  the  firms  in  this 
city  was  used  exclusively,  in  not  a  single  instance 
was  an  infection  traceable  to  this  source.  Most 
infections  of  the  skin  occur  when  a  hairy  territory 
is  invaded,  because  it  is  so  difficult  to  render  it 
aseptic,  and  not  because  the  catgut  is  at  fault.  If 
the  catgut  itself  were  responsible  for  the  ordinary 
stitch  infection,  why  is  it  that  the  skin  and  sub- 
jacent fascia,  or  the  skin  alone,  and  not  the  deeper 
strata  of  the  sutured  wound,  are  most  usually 
involved?  Why  is  it,  that  incisions  in  the  hypo- 
gastrium  near  the  pubes,  or  herniotomy  incisions, 
are  so  prone  to  this  complication,  while  when  ordi- 
nary precaution  is  taken,  incisions  elsewhere  on 
the  abdomen,  rarely  show  any  redness  or  signs  of 
local  infection  about  the  stitches? 

If  water  were  not  incompatible  with  the  catgut 
suture,  the  problem  of  catgut  sterilization  would 
be  a  comparatively  simple  one.  As  it  is,  steriliza- 
tion by  means  of  boiling  water,  or  superheated 
steam  is  out. of  the  question,  and  the  process  is 
usually  one  in  which  disinfection  and  dry  steriliza- 
tion in  its  various  forms,  are  combined.  A  further 
difficulty  presents  itself  in  this  that  the  medium  in 
which  the  catgut  is  kept  must  be  water- free,  other- 


Guiding  Principles  in  Surgical  Practice      71 


wise  the  tube  containing  it  cannot  be  boiled.  Cat- 
gut, plain  and  chromic,  thoroughly  desiccated,  is 
therefore  put  up  in  a  medium  consisting  of  chloro- 
form and  alcohol.  The  tube  containing  the  strand 
of  suture  material  is  but  half-filled  with  the  liquid 
to  allow  for  expansion,  and  can  be  boiled  re- 
peatedly to  sterilize  the  surface  without  impairing 
the  catgut.  With  this  preparation,  tubes  containing 
kangaroo  tendon  can  also  be  boiled,  whereas  if 
but  a  trace  of  water  were  present  the  suture  would 
swell  promptly  and  be  converted  into  a  rubber-like 
mass,  having  no  value  whatever  as  a  suture.  The 
tubes  are  boiled,  not  so  much  in  the  hope  of  re- 
sterilising  their  contents  as  to  render  their  surface 
aseptic  for  the  supply  table.  This  precaution  is  a 
vital  one,  because  the  surface  of  the  tubes  is  apt 
to  become  coated  with  a  fatty  layer,  and  bacterial 
contamination  is  the  result  of  handling.  If  they 
are  simply  immersed  in  antiseptic  solutions,  most 
of  which  in  addition,  as  corrosive  sublimate,  are 
practically  incapable  of  penetrating  the  fatty  de- 
posit, a  germicidal  action  upon  imbedded  bacteria 
is  doubtful  indeed.  If,  however,  the  glass  tubes 
are  subjected  to  the  boiling  process  in  slightly 
alkalinized  water  (1-1000  NaOH),  together  with 
the  instruments,  absolute  surface  sterility  is 
secured. 

The  question.  What  happens  in  the  interior  of 
the  tube  when  it  is  boiled?  is  a  natural  one.  In 
case  the  tube  contains  a  mixture  of  chloroform 
and  alcohol,  which  is  absolutely  water-free,  and 
whatever  may  be  the  temperature  to  which  this 
medium  rises,  when  such  a  tube  is  boiled  or  placed 
in  the  steam  sterilizer  with  the  dressings,  the  only 
sterilizing  effect  which  it  can  have  on  the  contained 


The  Surface 
of  the  Tubes 
is   Sterilized  by 
Boiling 


72       Guiding  Principles  in  Surgical  Practice 


Effect  of 

Boiling  on  the 

Catgut  Strand 

Within   the 

Tube 


strand   of   suture  material,   is   that   which   results 
from  the  action  of   dry  heat,   not  wet  heat;  any 
trace  of  moisture  due  to  water  in  the  tube,  would 
be  utterly  incompatible  with  the  catgut.    According 
to  the  manufacturers,  a  thermometer  suspended  in 
this  chloroform  mixture,  within  a  sealed  glass  tube, 
indicates    that    the    temperature    of    the    mixture 
reaches  approximately  the  temperature  of  the  sur- 
rounding   medium    in    the    sterilizer.      If    this    is 
correct,    the    additional    sterilizing    effect    of    this 
measure  would  be  equivalent,  in  the  one  case,  to 
that  of  a  dry  sterilisation  of  from  10  to  25  minutes 
at  about  100°  C.  (212°  F.),  and  in  the  other,  of  a 
dry  sterilization  of  not  less  than  35  minutes  dura- 
tion at  about  121°  C.  (250°  F.).    That  the  steriliz- 
ing effect  of  this  procedure  can  be  but  secondary 
in  importance  becomes  clear  when  the  degree  of 
heat  obtained,  and  the  time  are  compared  with  that 
which  is  necessary  to  insure  unquestionable  ster- 
ility by  dry  heat.     Thus   dry   sterilization  would 
require  about  three  hours  at  140°  C.  (284°  F.),  or 
about  two  hours  at  180°  C.  (356°  F.).    As  long  as 
no  water  is  admitted,  subjecting  such  tubes  to  the 
action  of  boiling  water  (100°  C),  or  steam  under 
pressure  (121°  C),  does  not  impair  the  quality  of 
the  suture.    It  is  only  when  the  dry  heat  is  carried 
considerably  beyond  this  point,  that  charring  re- 
sults, and  the  material  is  destroyed.    The  only  way, 
therefore,  in  which  satisfactory  sterilization  of  cat- 
gut can  be  obtained,  without  influencing  the  suture, 
is  not  by  a  single  dry  sterilization  at  very  high 
temperature,    but    by    repeated   sterilisation    at    a 
lower  degree  of  heat.    It  is  not  on  the  effectiveness 
of  a  single,  but  of  repeated  sterilisation  that  the 
sterility  of  surgical  catgut  really  depends. 


Guiding  Principles  in  Surgical  Practice      73 

To  a  great  extent  therefore,  the  guarantee  for 
the  undoubted  sterility  of  the  animal  suture  used 
at  operations  has  to  be  accepted  from  the  laboratory 
which  supplies  it.  It  would  be  desirable  to  apply 
wet  heat  either  by  boiling  or  by  means  of  steam 
under  pressure  to  all  suture  material,  but  until  an 
absorbable  material  which  cannot  be  destroyed  by 
hydration  is  found,  extemporaneous  sterilization 
by  these  methods,  is  out  of  the  question. 


Relation 
Between 

Surgeon    and 
Anesthetist 


CHAPTER  VIII 

The  Anesthesia 

It  is  not  my  purpose  to  enter  into  the  details  of 
the  technic  in  the  administration  of  anesthetics, 
only  so  far  as  this  may  be  helpful  in  bringing 
about  a  better  understanding  and  co-operation 
between  the  surgeon  and  his  anesthetist.  If  the 
surgeon  alone  is  to  be  held  responsible  for  the 
safety  of  his  patient,  he  cannot  be  indifferent  to  the 
methods  of  anesthesia  employed,  any  more  than  he 
can  disregard  the  asepsis  which  is  practiced  at  the 
operation  by  his  assistants  and  nurses.  If  the  sur- 
geon himself  has  had  a  thorough  training  in  anes- 
thetics— which  is  not  as  often  the  case  as  it  should 
be — he  is  in  a  better  position  to  work  together 
effectually  with  his  anesthetist;  if  he  lacks  this 
training,  he  may  allow  himself  to  interfere  where 
this  is  not  indicated,  and,  as  far  as  the  narcosis  is 
concerned,  may  unwittingly  put  himself  in  the  way 
of  the  proper  management  of  the  case.  It  is  easy 
to  understand,  that  pure  chloroform,  on  account  of 
its  greater  potency,  becomes  a  dangerous  narcotic 
in  the  hands  of  those  who  have  not  learned  to  use 
it  correctly.  The  solicitude  of  the  surgeon,  upon 
whom  perhaps  an  anesthetist  of  questionable  ex- 
perience has  been  thrust,  is  but  natural.  Indeed, 
there  are  legitimate  reasons  for  attempts  to  dis- 
place chloroforjn  by  the  less  toxic  ether,  as  a  rou- 
tine anesthetic.  Nevertheless,  thus  far  chloroform 
has  not  been  displaced,  because  of  certain  disad- 
vantages connected  with  the  use  of  ether  in  every- 

(74) 


Guiding  Principles  in  Surgical  Practice      75 


day  practice.  Its  greater  bulk  and  inflammability, 
the  fact  that  its  inhalation  is  more  disagreeable  to 
the  patient,  the  relatively  tedious  induction  of  nar- 
cosis when  it  is  used  uncombined,  the  increased 
tendency  to  cause  post-operative  nausea  and  vomit- 
ing, all  have  militated  against  ether  and  have 
helped  chloroform  to  retain  its  foothold,  notwith- 
standing its  toxicity.  It  is  true  that  the  induction 
can  be  shortened,  and  made  more  agreeable  to  the 
patient  by  preceding  with  nitrous-oxide  gas,  but 
the  exigencies  of  every-day  practice  prohibit  any 
cumbersome  apparatus  which  cannot  always  be  at 
hand. 

It  is  for  such  reasons  that  attempts  have  re- 
peatedly been  made  to  combine  the  desirable  prop- 
erties of  chloroform  and  ether,  and  to  neutralize 
the  objectionable  ones,  in  the  hope  of  obtaining  an 
ideal  anesthetic  for  general  routine.  One  of  the 
most  useful  of  these  anesthetic  solutions  is  anaes- 
thol — a  molecular  combination  of  chloroform 
(35.89%),  ethyl  chloride  (17%),  and  ether 
(47.10%). 

Essentially,  its  administration  differs  but  little 
from  the  administration  of  pure  chloroform.  It  is 
the  chloroform  content  of  anaesthol,  and  not  the 
ether,  that  dominates  the  narcosis,  although  the  de- 
pressant action  of  the  chloroform  is  counteracted 
to  some  degree  by  the  stimulant  influence  of  the 
ether  which  constitutes  almost  one-half  of  its  vol- 
ume. The  quantity  of  the  anesthetic  needed  is 
relatively  small — somewhat  greater  than  when 
pure  chloroform  is  used.  The  quantity  required 
for  an  anethesia  can  be  still  further  reduced  when 
a  quarter  of  a  grain  of  morphine  sulphate  is  given 
subcutaneously  half  an  hour  before  the  narcosis. 


Chloroform 
in   Everyday 
Practice 


The 

Administration 
of  Anaesthol 


76      Guiding  Principles  in  Surgical  Practice 


The   Use   of 

Oil  of  Rose  to 

Disguise   the 

Vapor 


Ether 
Feeding 


Cardiac 
Collapse 


In  an  average  case  15  to  20  cc.  of  anaesthol,  given 
on  a  mask  by  the  drop  method,  ought  to  suffice  for 
the  induction;  not  more  than  40  to  60  cc.  should 
be  consumed  during  the  entire  narcosis  lasting  an 
hour  or  more. 

From  the  patient's  standpoint  the  anesthesia  is, 
at  times,  a  matter  of  considerable  moment.  It  may 
be  the  recollection  of  the  ill-effects  of  a  former 
narcosis  that  deters  her  from  consenting  to  a  nec- 
essary measure.  Again,  the  odor  of  the  anesthetic 
may  become  markedly  repugnant  to  those  who 
have  previously  been  under  its  influence,  and  as- 
surance on  this  point  may  help  to  bring  about  a 
prompt  decision.  A  few  drops  of  a  10%  emulsion 
of  Persian  oil  of  rose  in  deodorized  alcohol  on  the 
mask,  is  an  efficient  way  of  eliminating  this  dis- 
agreeable element  in  the  induction  of  anesthesia. 

A  little  ether  is  kept  in  a  separate  drop  bottle, 
so  that  during  the  narcosis  with  anaesthol  its  stim- 
ulating effect  can  be  added  when  this  is  indicated 
— ether  feeding.  Or,  the  narcosis  may  be  contin- 
ued solely  with  ether  by  the  drop  method,  imme- 
diately after  the  induction  with  anaesthol,  should 
this  appear  advantageous.  There  is  thus  at  com- 
mand a  morphine-anaesthol  sequence,  or,  if  one 
wishes,  a  morphine-anaesthol-ether  sequence  which 
is  very  flexible  and  readily  adapts  itself  to  the  in- 
dividual case.  At  the  same  time  the  technic  which 
it  entails  is  strikingly  simple. 

The  chief  danger  with  chloroform  or  its  com- 
binations lies  in  its  action  upon  the  circulation — 
cardiac  collaps'e.  From  my  own  observations  true 
cardiac  collapse  is  very  rare.  Its  frequency  can  be 
estimated  to  be  about  2 :2000,  one-tenth  of  one  per 
cent,  of  all  cases  which  come  to  operation.     Since 


Guiding  Principles  in  Surgical  Practice      77 

it  is  during  the  induction  of  the  narcosis  that  this 
undue  susceptibility  usually  becomes  manifest,  the 
importance  of  alertness  and  caution  in  inducing 
with  chloroform  or  its  combinations  until  the  anes- 
thetist has  discovered  how  the  patient  responds  to 
the  narcotic,  cannot  be  overestimated.  In  this  con- 
nection the  question  is  pertinent  about  the  toler- 
ance of  the  patient  to  former  anesthetics.  In  im- 
pending collapse  of  the  heart,  there  is  increasing 
pallor  and  the  pulse  suddenly  becomes  diffuse  and 
weak.  If  the  induction  has  been  gradual  and  the 
anesthetist  attentive,  these  changes  may  be  discov- 
ered in  due  time  to  avert  disaster.  *.  ,.  .  r 
T  .  .  ,  ,  .  .  Abolition  of 
It  is  a  point  worth  knowing,  that  hearing  is  one  Hearing  and 

of  the  senses  which  may  be  abolished  rather  late  in  Consciousness 
the  induction,  and  that  the  patient  under  such  cir- 
cumstances may  hear  all  that  is  said  about  the 
operation  which  is  to  be  done.  In  fact,  the  com- 
plete abolition  of  consciousness  need  not  always 
take  place  when  morphine  has  been  administered, 
and  minimal  quantities  of  the  anesthetic  are  used. 
Thus,  I  recall  an  instance  (P.  R.  No.  4324)  in 
which  during  a  suprapubic  plastic  the  patient,  al- 
though insensitive  to  pain,  was  able  to  converse 
with  me  throughout  the  entire  procedure.  Others 
have  no  doubt  had  similar  experience.  This  illus- 
trates that  analgesia  sufficient  for  the  purpose  of 
the  surgeon,  must  not  invariably  be  accompanied 
by  complete  unconsciousness.  Abolition  of 

During  the  narcosis  it  is  better  for  the  patient  Reflexes 
to  be  in  a  tonic,  than  in  an  atonic  state,  as  far  as 
this  is  not  entirely  incompatible  with  the  require- 
ment of  the  surgeon.  A  slight  reaction,  for  ex- 
ample, when  the  initial  incision  is  made  is  not 
always  to  be  criticized;  if  the  anesthetist  is  uncer- 


78      Guiding  Principles  in  Surgical  Practice 


Erroneous 

Notion 

About  the 

Induction 

of  Shock 


tain,  it  is  wiser  to  allow  the  patient  to  be  a  little 
too  superficially,  than  at  once  too  profoundly  un- 
der the  influence  of  the  narcotic.  With  the  deeper 
respirations  of  the  patient,  a  few  drops  will  suffice 
to  annul  the  wakening  effect  of  the  initial  incision 
when  the  anesthetist  has  regained  his  bearings.  It 
is  not  to  be  lost  sight  of,  that  analgesia — freedom 
from  pain — is  the  first  aim  of  the  narcosis,  and  the 
reflexes  should  be  diminished  or  abolished  only  so 
far  as  they  become  a  hindrance  to  the  surgeon. 
When  morphine  has  been  administered,  the  reflexes 
may  remain  quite  active,  although  the  patient  is  in 
the  proper  state  of  analgesia,  and  in  the  correct 
surgical  plane.  If  the  surgeon  is  gentle  in  his 
work,  as  he  should  be,  not  only  on  account  of  the 
delicate  make-up  of  the  structures  which  he  is 
handling,  but  also  in  order  to  avoid  any  unwar- 
ranted exaggeration  of  the  numerous  ingoing  im- 
pulses to  the  cord  and  brain,  this  property  of  mor- 
phine will  very  rarely  prove  to  be  an  objection  to 
the  use  of  the  drug. 

The  notion  that  shock  will  follow,  because  some 
of  the  reflexes  are  still  active  during  the  course  of 
an  operation,  is  surely  not  founded  on  experience. 
If  the  patient  remains  passive  and  feels  no  pain, 
the  prime  object  of  the  anesthesia  is  usually  at- 
tained. In  abdominal  and  pelvic  surgery,  it  is  not 
always  in  the  patient's  interest  to  insist  on  flaccid 
abdominal  muscles  during  operation.  The  muscles 
may  be  relaxed,  but  they  must  not  be  paralyzed  by 
the  anesthetic.  The  surgeon  who  is  too  violent  or 
precipitate  in  the  execution  of  his  work,  will  con- 
tinually complain  that  the  abdominal  wound  can- 
not be  satisfactorily  retracted,  and  the  patient  is 
insufflciently  under  the  influence  of  the  anesthetic. 


Guiding  Principles  in  Surgical  Practice      79 


This  is  a  dangerous  failing,  and  may  lead  the  nar- 
cotizer  of  limited  experience  to  attempt  to  subdue 
the  resisting  patient  with  the  narcotic,  instead  of 
anesthetizing  her.  Crowding  the  anesthetic  is  one 
of  the  chief  sources  of  trouble  in  drop-method  nar- 
cosis. The  insufficient  dilution  of  the  anesthetic 
with  air  incident  upon  crowding,  brings  with  it  the 
inhalation  of  vapors  which  are  too  irritating  to  the 
glottis  because  of  their  great  concentration.  The 
increasing  spasm  of  the  larynx  which  results,  im- 
pedes free  respiration,  and  instead  of  anesthesia, 
a  state  of  asphyxia  is  induced,  which  finally  cul- 
minates in  respiratory  collapse.  A  change  in  the 
quality  of  the  breathing  sound  indicated  by  the 
appearance  of  a  few  faint  high-pitched  notes,  to- 
gether with  the  advent  of  a  slight  tinge  of  cyanosis, 
are  the  significant  premonitors  of  this  condition. 
It  is  then  not  more  of  the  anesthetic,  but  less  of  it, 
that  the  struggling  patient  wants.  A  little  fresh  air 
admitted  by  raising  the  mask,  dissolves  the  spasm 
of  the  larynx,  and  strange  as  it  may  seem  to  the 
inexperienced,  the  patient  who  now  inhales  the  di- 
luted vapors  freely,  instead  of  awakening,  relaxes 
the  resisting  muscles  and  relapses  into  a  tranquil 
narcosis.  The  secret  of  success  in  an  anaesthol 
or  for  that  matter  in  a  chloroform  narcosis,  lies  in 
the  systematic  avoidance  of  crowding. 

Coughing  should  not  necessarily  convey  the  im- 
pression to  the  operator  that  the  patient  is  about 
to  become  conscious.  It  is  frequently  due  to  irri- 
tation of  the  pharynx,  and  may  occur  at  any  time 
during  the  course  of  the  operation,  if  the  mask  is 
suddenly  charged  with  the  anesthetic,  instead  of 
supplying  it  uniformly,  drop  by  drop. 


The  Chief 
Failing  in 
the   Use  of 
Chloroform 
or  its 
Combinations 


The 

Coughing 

Reflex 


80      Guiding  Principles  in  Surgical  Practice 

Vomiting  Vomiting  efforts  constitute  a  disagreeable  inter- 
ruption, but  the  deep  breaths  which  are  inter- 
polated make  it  easy  to  regain  the  surgical  plane. 
The  head  of  the  patient  is  quickly  turned  to  one 
side  without  pushing  the  jazv  forward,  the  mouth 
wiped  and  the  anesthetic  continued,  while  the  sur- 
geon co-operates  by  desisting  for  the  moment  from 
traction  on  the  mesentery,  or  other  manipulations 
which  may  have  given  rise  to  the  potent  awakening 
impulse. 
y  Very  dark  blood  at  the  wound  may  indicate  that 

Blood  t^^  patient's  breathing  is  embarrassed.     The  cause 
may  be  mechanical,  as  when  the  saliva  accumulates 
in  the  mouth,  or  the  tongue  recedes,  or  a  shoulder- 
-  brace  presses  against  the  throat,  or  there  is  valve- 
action  of  the  lips  in  the  old  who  have  been  wear- 
ing    a     tooth-plate,     or     adenoid     obstruction     in 
children.   When  it  is  not  feasible  to  remove  the  ade- 
•  noids  before  operation,  I  know  of  no  simpler  way 
of  coping  with  this  difficulty,  than  by  the  use  of 
The  ^^^    breathing    tube.      A    soft    rubber    catheter    is 

Breathing  passed  through  one,  or  both  of  the  child's  nostrils. 
Tube  beyond  the  adenoid  ring  of  Waldeyer  into  the 
laryngo-pharynx  (Practical  Points  in  Anesthesia, 
1908).  This  manoeuvre  is  not  only  useful  in  the 
case  of  adenoids,  but  also  in  some  of  the  other 
causes  of  mechanical  obstruction,  such  as  recession 
of  the  tongue.  Occasionally,  its  use  may  be  of  diag- 
nostic value  in  satisfying  the  anesthetist  that  the 
respiratory  impediment  in  a  given  case  is  due  to 
laryngeal  spasm — ^the  usual  result  of  insufhcient  di- 
lution of  the  anesthetic  with  air. 
Pulse  It  is  a  good  rule  for  the  surgeon  to  make  a  mental 
note  of  the  quality  of  the  patient's  pulse  before  the 
operation.    He  is  then  in  a  better  position  to  judge 


Guiding  Principles  in  Surgical  Practice      81 


the  post-operative  condition,  or  to  appreciate  any 
marked  change  in  its  normal  characteristics.  In 
weighing  tlj^  necessity  for  post-operative  stimula- 
tion, the  surgeon  should  not  allow  the  fact  to  escape 
him,  that  nausea  and  vomiting,  occurring  as  the  sub- 
ject recovers  from  the  anesthetic,  may  cause  a 
transitory  irregularity  in  the  pulse  which  is  of  no 
serious  significance.  Furthermore,  in  the  case  of 
some  anesthetics,  as  anaesthol  or  ether,  a  stimulant 
effect  of  the  nalrcotic  upon  the  pulse  may  occasion- 
ally persist  for  a  very  brief  period  after  operation. 

The  amount  of  shock  to  which  the  patient,  in  a 
particular  case,  is  subjected,  does  not  depend  so 
much,  for  example,  on  the  actual  extent  to  which 
the  abdominal  viscera  are  handled,  but  rather  on  the 
manner  in  which  this  is  done.  Thus,  the  entire  mass 
of  small  intestines  can  be  gently  withdrawn  from 
the  abdominal  cavity  for  systematic  inspection, 
without  of  necessity  producing  in  the  patient  the 
slightest  evidences  of  post-operative  shock, 

A  great  deal  might  be  said  about  apparent  and 
real  contra-indications  to  the  administration  of 
anesthetics.  A  common,  but  erroneous  impression 
is  that  heart  murmurs  corresponding  to  a  valvular 
lesion,  necessarily  contra-indicate  narcosis.  As  a 
miitter  of  fact,  it  is  not  so  much  the  hearts  that  have 
murmurs,  least  of  all  the  hearts  that  have  loud  mur- 
murs that  presage  a  perilous  narcosis,  but  the  degree 
of  myocardial  involvement  is  the  salient  factor. 
Thus,  the  heart  with  a  degenerated  muscle,  scarcely 
capable  of  producing  an  audible  murmur,  comfnands 
the  greatest  solicitude  during  the  administration  of 
the  anesthetic.  Particularly  pure  chloroform,  is  out 
of  place  in  such  a  lesion. 


Estimating 
the  Amount 
of 

Post-operative 
Shock 


Heart 
Disease  in 
Anesthesia 


82      Guiding  Principles  in  Surgical  Practice 


Epilepsy 


Anesthesia 

in 

Tuberculous 

and 

Diabetic 

Subjects 


The    Choice 

Between 

Chloroform 

and  Ether 


Epilepsy  does  not  contra-indicate  the  giving  of  an 
anesthetic,  nor  the  execution  of  an  operation;  in 
fact,  epileptic  seizures  of  reflex  origin,  occasionally 
disappear  after  a  simple  narcosis  or  operation. 

Great  judgment  must  be  exercised  in  establishing 
the  indication  for  narcosis  and  operation  in  all  sub- 
jects with  tuberculous  lesions  of  the  lung;  the  dan- 
ger lies  in  the  exaggeration  of  an  active  process, 
or  in  the  enkindling  of  a  latent  one.  Moreover, 
operation  performed  in  a  tuberculous  territory,  in 
any  part  of  the  body,  it  is  well  known,  may  lead 
to  dissemination  of  the  trouble.  In  diabetic  pa- 
tients, where  there  is  2%  or  more  of  sugar  which 
is  not  influenced  readily  by  diet,  coma  is  very 
prone  to  follow  narcosis  and  operation,  and  seems 
to  be  directly  or  indirectly  precipitated  by  these 
measures.  It  is  in  these  two  groups  of  cases,  that 
both  ether  and  chloroform  or  its  combinations  have 
distinct  disadvantages,  and  while  there  is  available 
no  entirely  satisfactory  form  of  narcosis,  nitrous 
oxide-oxygen  correctly  administered,  holds  a  legiti- 
mate place.  It  may  be  that  as  soon  as  the  construc- 
tion of  the  necessary  apparatus  can  be  simplified, 
and  its  weight  and  bulk  reduced  to  make  it  really 
portable,  the  nitrous  oxide-oxygen  sequence  will 
receive  the  wider  application  in  practice,  which  it 
deserves. 

While  I  have  repeatedly  voiced  the  use  of  anaes- 
thol — chloroform  modified  to  increase  its  safety 
without  impairing  its  anesthetic  usefulness — as  an 
acceptable  substitute  for  chloroform  in  every-day 
practice,  I  would  not  convey  the  impression  that  I 
am  inimical  to  the  choice  of  an  uncombined  ether 
narcosis,  only  in  so  far  as  it  is  not  practical.  In 
addition,  it  is  clear  that  the  rigid  adherence  to  any 


Guiding  Principles  in  Surgical  Practice      83 


routine,  would  be  foreign  to  one  who  believes  in 
adapting  the  anesthesia  to  the  peculiarities  of  the 
case.  As  a  routine  procedure,  it  is  true,  the  mor- 
phine-anaesthol  sequence  with  or  without  the  addi- 
tion of  ether,  allows  considerable  latitude  for  in- 
dividualization. But  this  will  not  always  suffice  to 
meet  the  special  requirements  in  special  cases. 

In  operations  on  the  brain  and  cranial  nerves  it 
is  not  difficult  for  the  anesthetist  to  maintain  the 
surgical  plane,  because  the  awakening  stimuli  set  up 
during  the  operation  are  slight.  But  it  is  a  distinct 
advantage  to  have  the  anesthetist  away  from  the 
surgeon's  precinct.  Instead  of  using  the  ordinary 
mask,  the  anesthetic  is  therefore  administered 
through  a  funnel,  covered  with  gauze,  and  connected 
with  one  or  two  rubber  tubes  which  conduct  the 
anesthetic  vapors.  In  this  very  simple  form  of  tube 
narcosis,  the  tube  passing  the  base  of  the  tongue 
enters  the  laryngo-pharynx,  but  not  the  larynx  itself. 
If  chloroform  or  anaesthol  are  used,  and  a  full  dose 
of  morphine  was  given  half  an  hour  before  the  nar- 
cosis, to  diminish  the  amount  of  anesthetic  required, 
it  ought  ordinarily  to  be  a  comparatively  easy 
matter  to  keep  the  patient  sufficiently  under  the  in- 
fluence of  the  narcotic.  If  there  is  difficulty  experi- 
enced in  doing  this,  it  may  be  that  the  calibre  of 
the  tube  or  tubes  employed  is  too  small.  In  a  cere- 
bellar tumor,  or  a  tumor  of  the  acoustic  nerve, 
when  an  occipital  flap  must  be  made,  and  the  pa- 
tient's face  is  turned  downward,  the  anesthetist 
may  be  seated  at  the  foot  of  the  patient,  or,. in  some 
cases,  advantageously  out  of  the  way  of  the  surgeon 
and  his  assistants  and  nurses,  on  a  stool  beneath 
the  operating  table  itself. 


Narcosis  in 
Operations 
on  the  Brain 
and  Cranial 
Nerves 


84       Guiding  Principles  in  Surgical  Practice 


Narcosis  in 

Tumors  of  the 

Larynx 


Intratracheal 

Insufflation 

Narcosis  for 

Intrathoracic 

Operations 


In  extrinsic  tumors  of  the  larynx,  after  opening 
the  throat  by  subhyoidean  pharyngotomy,  the  nar- 
cosis by  this  method  is  not  feasible.  The  tube  in- 
stead of  merely  approaching  the  vicinity  of  the 
larynx,  must  be  passed  into  it  and  the  trachea.  The 
surgeon  selects  a  rubber  tube  of  about  the  thickness 
of  a  stomach  tube  which  has  been  sterilized  for  the 
purpose,  and  introduces,  first,  the  end  with  the  eye, 
into  the  trachea,  ascertains  that  the  respiratory  air 
streams  freely  through  it,  and  then,  at  once  delivers 
the  other  end  to  the  anesthetist,  upward  through  the 
patient's  mouth,  where  it  should  be  fixed  with  ad- 
hesive plaster  to  prevent  dislodgment.  In  this  man- 
ner the  asepsis  at  the  field  of  operation  is  not  vio- 
lated, as  it  would  be,  if  the  tube  were  first  passed 
through  the  mouth  into  the  surgeon's  hands,  before 
reaching  the  trachea. 

In  operations  in  which  the  pleura  has  to  be 
opened,  or  may  be  opened  accidentally,  it  becomes 
vital  to  prevent  collapse  of  the  lung.  In  the  intra- 
tracheal insufflation  method  of  anesthesia  developed 
by  Meltzer  and  Auer,  this  difficulty  is  obviated  in  a 
strikingly  simple  way.  Here  a  single  rubber  cathe- 
ter which  is  not  too  thin-walled,  and  about  No.  22 
French  scale,  is  introduced  to  the  vicinity  of  the 
bifurcation  of  the  trachea,  and  a  stream  of  oxygen 
mixed  with  ether  vapor  of  a  concentration  not  ex- 
ceeding 6  to  7  per  cent.,  serves  the  double  purpose 
of  assisting  in  the  inflation  of  the  lungs,  and  main- 
taining the  anesthesia.  To  avoid  the  repetition  of 
fatalities  caused-  by  abrupt  distention  of  the  lung, 
no  apparatus  of  this  description  should  be  used  on 
the  human  subject,  unless  it  is  supplied  with  an 
adequate  safety  valve  (H.  Fischer). 


Guiding  Principles  in  Surgical  Practice      85 


Since  the  creation  of  the  first  separate  department 
for  intrathoracic  surgery  in  this  country,  at  the 
German  Hospital  of  this  city — the  result  of  the 
untiring  energy  of  Willy  Meyer  and  his  brother,  J. 
Meyer — unique  opportunity  for  the  study  of  the 
comparative  value  of  these  methods  is  afforded.  I 
had  occasion  to  be  incarcerated  in  the  positive  dif- 
ferential pressure  compartment  repeatedly,  when  the 
first  trials  of  this  modified  Sauerbruch-Brauer 
chamber  were  made  at  the  hospital,  and  it  seems  to 
me  that  the  current  impression  of  the  great  dis- 
comfort of  the  narcotizer,  and  the  difficulties  that 
beset  him  under  these  circumstances  is  not  well 
founded.  The  vapors  of  the  anesthetic  do  not 
accumulate  in  the  chamber,  the  space  is  sufficiently 
large  to  accommodate  an  assistant  if  one  should  be 
needed,  it  is  possible  to  leave  the  cabinet  through 
the  vestibule,  without  exposing  the  patient  who  is 
under  narcosis  to  a  sudden  change  in  the  atmos- 
pheric pressure.  Outside  of  the  slightly  disagree- 
able sensation  produced  in  the  ear-drums  of  the 
occupant  when  the  pressure  within  the  cabinet  is 
raised  or  lowered,  and  the  disturbing  vibration 
caused  by  the  action  of  the  ponderous  pumps,  the 
conditions  under  which  the  anesthetist  has  to  work 
are  but  little  dififerent  from  those  in  the  ordinary 
operating-room.  The  air-tiglit  rubber  collar  some- 
what encumbers  the  manipulation  of  the  patient's 
head,  but  the  difficulty  is  largely  overcome  when  the 
latter  is  placed  on  a  small  head-rest  which  is  sus- 
pended in  an  adjustable  sling  or  hammock.  In  the 
administration  of  the  anesthetic,  in  general,  the  same 
rules  hold  good  as  in  narcosis  elsewhere — the  ap- 
paratus has  to  do  only  with  the  counteracting  of 
the   abnormal   rise    in   pressure   produced   in    the 


Anesthesia 
in  the  Positive 
Differential 
Pressure 
Cabinet 


86      Guiding  Principles  in  Surgical  Practice 

pleural  cavity  by  the  inrush  of  air  when  the  thorax 
is  opened,  and  to  prevent  the  lung  from  collapsing 
thereafter. 

During  one  of  the  operations  executed  with  the 
aid  of  the  apparatus,  I  have  had  occasion  to  observe 
a  peculiar  series  of  events  during  which  the  pupils 
Death  by  dilated  and  the  patient  rapidly  collapsed,  and  which 
Asphyxia  I  have  been  unable  to  explain,  except  that  it  ap- 
peared likely  that  the  fatality  was  not  due  to  the 
action  of  the  anesthetic  or  any  unusual  manipula- 
tion on  the  part  of  the  anesthetist,  but  rather  the 
result  of  some  manoeuvre  incident  upon  the  opera- 
tion itself.  Dr.  J.  Meltzer  has,  I  think,  offered  the 
first  scientific  solution.  He  emphasizes  that  under 
the  Brauer  method,  life  is  sustained  by  a  small  part 
of  the  normal  respiration  (minimum,  1/lOth  of  the 
normal).  The  only  portion  of  the  lung  which  is 
active  in  aeration  under  these  extreme  conditions 
is  the  posterior  part  of  the  lower  lobe.  Any  manipu- 
lation on  the  part  of  the  surgeon  which  interferes 
with  the  function  of  this  portion  of  the  lung,  such 
as  pushing  it  to  one  side  during  exploration,  or 
compression  of  it,  or  expulsion  of  its  air  content 
by  dislodging  it,  or  lifting  it  out  of  the  chest,  may 
suffice  to  bring  about  a  rapid  exitus  by  asphyxia. 

At  the  present  time,  when  thoracic  surgery  has 
just  received  a  new  impulse,  it  is  impossible  to  pass 
final  judgment  on  the  relative  practical  value  of  the 
differential  and  intra-tracheal  insufflation  methods 
of  anesthesia.  However,  the  general  drift  seems 
to  be  towards  the  adoption  of  the  intra-tracheal 
insufflation  method  for  routine  thoracic  surgery, 
limiting  the  scope  of  the  differential  pressure  method 
to  special  cases. 


CHAPTER  IX 


The  Incision 


In  surgical  treatment  the  division  of  healthy  tissue 
often  becomes  necessary,  in  order  to  make  the  seat 
of  disease  or  injury  accessible.  Since  the  integrity 
of  the  structures  which  have  been  deliberately 
divided  must  again  be  restored,  it  is  a  matter  of 
moment  how  this  division  is  done.  Operations  on 
the  abdominal  and  pelvic  organs  form  such  a  large 
part  of  the  routine  in  major  surgery,  and  the  ab- 
dominal route  is  so  frequently  chosen,  that  a  careful 
study  of  the  parietal  incision  with  the  view  of  avoid- 
ing disagreeable  sequelae  such  as  neuralgia,  deform- 
ing scars  and  post-operative  hernia,  is  distinctly 
worth  while.  But  the  ideal  incision,  besides  being 
in  itself  a  conservative  one,  must  allow  of  extension 
without  undue  mutilation  of  the  anatomic  entities 
which  constitute  the  abdominal  wall.  Viewed  in 
this  light,  very  few  of  the  stereotype  methods  ordi- 
narily practised  can  be  considered  exemplary. 

One  of  these,  however,  which  illustrates  the  gen- 
eral principles  involved  in  the  make-up  of  correct 
parietal  incisions,  has  been  pointed  out  by  Pfan- 
nenstiel,  Stimson  and  others  for  operation  on  the 
pelvic  organs  and  the  lower  abdomen — the  semilunar 
hypogastric  incision  combined  with  the  median 
separation  of  the  recti.  The  incision  is  carried 
across  the  abdomen  in  a  shallow  curve,  the  con- 
vexity of  which  usually  corresponds  to  a  point  one- 
half  to  three-quarters  of  an  inch  above  the  symphysis 
pubis.    It  begins  and  ends  one  and  a  half  inches  or 

(87) 


Conservative 
Incisions 


Semilunar 

Hypogastric 

Incision 


88       Guiding  Principles  in  Surgical  Practice 


Division 

o£  the 

Subcutaneous 

Fatty 

Tissue 


less,  above  the  midpoint  of  Poupart's  ligament  on 
each  side.  Its  correct  course  is  indicated  by  the 
furrow  or  sulcus  of  a  more  or  less  pronounced 
suprapubic  fold,  which  is  found  in  this  location. 

Since  the  greater  portion  of  the  incision  lies  in  the 
hairy  area  of  the  pubic  region,  the  difficulty  of 
rendering  the  skin  aseptic  may  be  cited  as  an  objec- 
tion to  its  general  use.  But  experience  has  shown, 
I  think,  that  such  an  objection  does  not  militate 
against  its  adoption.  If  the  area  is  carefully  shaved, 
and  cleansed  with  soap  suds  when  the  patient  is 
admitted,  and  on  the  evening  before  operation  any 
one  of  the  compatible  iodine  solutions  is  applied  for 
preliminary  disinfection  of  the  points  which  are 
inaccessible  to  the  final  mechanical  cleansing  in  the 
operating-room,  and  the  skin  is  kept  covered  during 
the  operation  with  sterile  towels  which  are  prevented 
from  dislodging  by  means  of  Backhaus'  towel 
clamps,  there  need  be  little  fear  that  contamination 
of  the  wound  will  occur  from  a  surface  which  is 
not  surgically  clean. 

In  the  semilunar  hypogastric  incision  the  sub- 
cutaneous fat,  that  is,  the  superficial  layer  of  the 
superficial  fascia  or  Camper's  fascia,  is  split  at  once 
down  to  the  dense  structure  which  represents  the 
deep  layer  of  the  superficial  fascia,  Scarpa's  fascia. 
The  depth  of  the  wound  at  this  stage  varies  greatly 
with  the  development  of  the  panniculus  adiposus 
and  may  be  less  than  one-quarter  inch  or  more  than 
two  inches.  The  amount  of  venous  bleeding  also 
varies,  and  is  naturally  greater  when  there  is  venous 
stasis.  Most  of  the  bleeding  from  the  fat  is  due  to 
venous  oozing,  and  is  arrested  by  means  of  dry 
gauze,  or  if  this  fails  gauze  sponges  wrung  in  boiling 
water.    Usually  it  is  only  four  points  that  have  to  be 


Guiding  Principles  in  Surgical  Practice      89 


secured  by  hemostatics — the  divided  ends  of  the 
superficial  epigastric  artery,  in  the  right  and  left 
halves  of  the  upper  and  lower  flaps.  The  branches 
of  the  superficial  external  pubic  on  the  other  hand, 
which  ascend  to  the  zone  just  above  the  pubes,  are 
so  minute  that  they  do  not  require  clamping  at  all. 
The  bleeding  points  need  rarely  be  ligated;  by  the 
time  the  wound  is  closed,  or  before  this,  forcipres- 
sure  alone  will  have  sufficed  to  insure  hemostasis. 
Ligating  these  vessels  merely  consumes  time,  hinders 
the  re-establishment  of  the  blood  flow  across  the 
scar,  while  the  knots  of  catgut,  until  they  are  dis- 
posed of,  act  as  foreign  bodies  in  the  wound. 

By  means  of  the  gloved  index  finger,  covered 
with  a  layer  of  gauze,  the  loosely  attached  fat  is 
easily  brushed  from  the  surface  of  the  dense  fascia, 
exposing  it  to  view,  and  widening  the  path  of  the 
incision.  Scarpa's  fascia  is  intimately  adherent  to 
the  anterior  rectus  sheath,  and  the  separation  would 
be  more  or  less  artificial,  so  that  in  this  procedure 
both  are  best  treated  as  if  they  constituted  but  a 
single  layer.  The  scalpel  is  carried  through  the 
structure  transversely  on  each  side  of  the  median 
raphe,  until  the  red  muscle  appears;  a  small  blunt 
scissors  is  slipped  into  the  opening,  and  the  incision 
is  extended  to  each  side.  While  the  incision  through 
the  skin  follows  the  lines  indicated  by  the  natural 
crease,  and  is,  as  a  rule,  a  shallow  curve,  the  line  of 
fascial  division,  should  approach  a  semicircle,  in 
order  to  obtain  a  flap  which  permits  of  better  ex- 
posure. This  point,  I  believe,  is  sometimes  over- 
looked, and  its  non-observance  may  help  to  explain 
the  difficulty  which  is  occasionally  experienced  in 
getting  sufficient  working  room  with  the  semilunar 
hypogastric   incision.      The   normal   limits    of    the 


Scarpa's 
Fascia  and 
Anterior 
Rectus 
Sheath 


90      Guiding  Principles  in  Surgical  Practice 


Lifting 

the  Fascial 

Flap  and 

Liberating 

the  Rectus 

Muscle 


incision  are  the  lateral  borders  of  the  recti  muscles ; 
in  other  words,  it  does  not  extend  beyond  the  lateral 
confines  of  the  rectus  sheath,  so  that  the  dorsal 
nerves  which  enter  it  here  to  supply  the  muscle  are 
not  cut.  As  a  rule,  any  separation  of  living  tissues 
from  each  other  w'hich  is  not  imperative,  is  to  be 
looked  upon  as  harmful;  but  it  is,  in  this  case, 
essential  to  free  the  unyielding  fascia  from  all  its 
subjacent  connections.  This  is  easily  done  by  lift- 
ing the  border  of  the  upper  fascial  flap,  first  on  one, 
and  then  on  the  other  side  of  the  median  raphe, 
while  the  index  finger  is  passed  beneath  it  and  strips 
it  away  from  the  anterior  surface  of  the  rectus 
muscle.  Sometimes  a  few  strokes  of  the  scalpel, 
may  be  required  to  free  the  sheath  from  a  tendinous 
inscription  which  occurs  at  this  low  level.  The 
median  raphe  is  then  divided  by  means  of  scissors, 
while  it  is  put  upon  the  stretch  between  forceps. 
The  division  of  this  line  of  attachment  must  be 
continued  upward  to  the  extent  of  two  or  three 
inches.  In  a  similar  manner,  the  inferior  fascial  flap 
is  separated  as  far  as  the  crest  of  the  pubic  bone. 
Beneath  the  fascia,  the  rectus  abdominis  muscle  is 
attached  by  a  tendon  to  the  crest  of  the  pubes. 
When  the  pyramidalis  muscles  are  absent,  there  may 
be  noted  in  their  stead,  in  front  of  this  tendon,  near 
the  median  line,  a  small  tendinous  process  which 
can  be  traced  to  the  anterior  surface  of  the  sym- 
physis pubes,  when  the  lower  fascial  flap  is  raised. 
At  this  stage,  the  lower  flap  of  fascia  is  incised  in 
the  middle  line,  as  far  as  the  pubic  bone — pubic 
extension.  The  incision  is  only  one-half  to  three- 
quarters  of  an  inch  long,  so  that  the  danger  of  post- 
operative hernia  at  this  point  may  be  disregarded, 
while  the  advantage  gained  in  securing  a  wider  ex- 


Guiding  Principles  in  Surgical  Practice      91 


posure  is  so  decided,  that  it  seems  best  to  use  the 
pubic  extension  as  a  routine. 

To  understand  fully  why  the  recti  muscles  are  so 
promptly  mobilized,  and  can  be  pulled  away  from 
the  median  line  like  two  yielding,  elastic  bands,  it 
must  be  borne  in  mind  that  in  this  location  the  re- 
sistant rectus  sheath  is  absent  posteriorly,  and  the 
muscle  is  but  loosely  connected  with  a  supple  trans- 
versalis  fascia  and  peritoneum.  The  replacement  by 
a  narrow  strip  of  rigid  connective  tissue  of  one  or 
both  pyramidalis  muscles,  likewise  affects  the  readi- 
ness with  which  the  recti  muscles  can  be  retracted. 
When  the  pyramidalis  muscles  are  present,  the  open- 
ing is  usually  effected  by  entering  between  them; 
sometimes  it  is  indicated  to  enter  to  one  side.  In 
either  case,  some  mutilation  of  the  tapering  apices 
can  hardly  be  avoided. 

On  retracting  the  muscle  bands  with  McBurney 
retractors,  the  transversalis  fascia  and  peritoneum 
present  themselves,  and  are  opened  at  a  high  level 
in  the  wound,  by  making  a  minute  incision  between 
forceps.  With  the  inrush  of  air,  the  intestinal  coils 
at  once  recede  and  the  peritoneal  opening  is  en- 
larged, at  first  upward,  and  then  cautiously  down- 
ward, to  avoid  incising  the  bladder.  The  summit 
of  the  empty  bladder  reaches  the  level  of  the  pubic 
crest.  By  palpating  the  peritoneum  between  the 
thumb  and  finger,  or  by  raising  it  so  that  it  can  be 
trans-illuminated  before  dividing  it,  accidental  in- 
jury to  the  bladder  can  easily  be  prevented.  A  thick 
layer  of  properitoneal  fat  should  not  be  mistaken 
for  adherent  omentum.  If  in  doubt,  it  is  severed 
cautiously  in  a  perpendicular  line,  when  the  peri- 
toneum itself  will  soon  appear  and  the  small  bowel 
can  be  seen  to  move  freely  beneath  it.    In  the  pro- 


Section  of  the 
Transversalis 
Fascia  and 
Peritoneum 


92      Guiding  Principles  in  Surgical  Practice 

peritoneal  fat,  between  the  transversalis  fascia  and 
the  peritoneum,  lie  the  deep  epigastric  arteries  on 
each  side,  accompanied  by  their  venae  comites.  But, 
approaching  in  their  upward  course,  the  fold  of 
Douglas,  they  pierce  the  transversalis  fascia  and 
enter  the  rectus  sheath.  In  this  part  of  their  course 
they  lie  between  the  posterior  surface  of  the  rectus 
muscle  and  the  posterior  lamella  of  its  sheath.  It 
is  well  to  be  heedful  of  this  relation.  I  have  in  mind 
a  fatality  in  a  case  in  which  an  autopsy  was  not 
obtained,  in  which  it  seemed  likely  that  exitus  was 
due  to  internal  hemorrhage  from  the  deep  epigastric 
artery  injured  in  abdominal  repair. 

At  the  close  of  the  operation,  the  wound  is  re- 
paired layer  by  layer.  The  peritoneum  is  closed 
Suture  of  with  a  contiuous  spiral  suture  of  No.  0  40-day 
the  Wound  chromic  catgut,  while  a  hemostatic  at  the  upper  and 
lower  angles  of  the  opening,  lifts  it  away  from  the 
bowel.  To  accelerate  this  step  two  stitches  are 
taken  each  time  before  the  catgut  thread  is  tightened. 
To  correct  the  recession  of  the  peritoneum  from  the 
abdominal  parietes  as  it  approaches  the  top  of  the 
bladder,  and  to  give  this  point  additional  support, 
one  or  two  interrupted  sutures  of  No.  1  or  2  40-day 
chromic  catgut  may  be  employed  to  bring  the  mus- 
cles together,  and  allowed  to  traverse  the  space  of 
Retzius,  including  the  fibrous  cord,  the  obliterated 
urachus,  which  can  be  felt  as  a  thickening  beneath 
the  peritoneum.  When  the  repair  of  the  muscle 
layer  is  complete,  palpation  of  the  suture  line  with 
the  finger,  above  all,  at  the  upper  and  lower  angles 
of  the  incision,  should  reveal  a  uniformly  firm  re- 
sistant seam,  without  any  yielding  interstices.  Ex- 
ceptionally, for  example,  in  pre-existing  diastasis  of 
the  recti,  simple  or  compound,  interrupted  mattress 


Guiding  Principles  in  Surgical  Practice      93 


sutures  may  be  indicated,  and  the  attenuated  muscle 
planes  are  overlapped.  In  closing  the  fascial  in- 
cision, it  is  to  be  observed  that  the  anterior  rectus 
sheath  which  is  here,  in  itself,  quite  thick,  being 
formed  by  the  complete  fusion  of  the  aponeurosis 
of  the  external  oblique,  the  internal  oblique  and  the 
transversalis  muscles ;  is  also  re-enforced,  by  the 
deep  layer  of  the  superficial  fascia — Scarpa's  fascia 
— which  is  particularly  well  developed,  and  rich  in 
elastic  fibres.  In  general,  the  anterior  rectus  sheath 
and  Scarpa's  fascia  are  found  to  be  quite  adherent, 
although  at  the  angles  of  the  semicircular  incision 
their  individuality  is  easily  demonstrable.  After 
both  layers  have  been  made  to  coincide  at  the  ends 
of  the  wound,  the  angles  are  clamped  temporarily 
to  aid  the  suture  en  masse.  Before  this  step,  the 
patient  must  have  been  returned  from  the  Trend- 
elenburg to  the  horizontal  posture,  to  obviate  un- 
necessary tension.  As  a  rule,  the  tension  is  not 
marked ;  if  notable,  it  is  most  apparent  in  the  center 
of  the  incision,  and  at  this  point  a  few  interrupted 
sutures  of  No.  1  or  2  40-day  chromic  catgut  may  be 
placed,  while  the  remaining  wound  is  repaired  by 
means  of  a  continuous  glover's  stitch,  of  the  same 
material.  When  the  pubic  extension  has  been 
practised,  both  corners  of  the  fascial  flap  thus 
formed  must  previously  be  caught  with  clamps  and 
reunited.  A  simple  mattress  stitch  is  most  efificient 
in  bringing  together  the  corners,  and  drawing  them, 
at  the  same  time,  upward  against  the  margin  of  the 
upper  fascial  flap  at  its  midpoint.  To  prevent  gap- 
ing, a  continuous  spiral  suture  of  No.  000  or  0 
40-day  chromic  catgut  is  introduced  into  the  sub- 
cutaneous fat  when  it  is  abundant,  that  is,  when  the 
layer  exceeds  a  quarter  inch  in  thickness.     Skin 


Successive 
Steps    in 
Closing  the 
Wound 


94      Guiding  Principles  in  Surgical  Practice 

coaptation  is  accomplished  by  means  of  Michel's 
clamps,  which  are  removed  at  the  first  dressing,  on 
the  fifth  or  seventh  day.  By  this  method,  generally 
the  most  satisfactory  closure  of  the  skin  wound  is 
obtained  in  this  region.  In  many  cases  there  re- 
mains a  scarcely  discernable  scar  hidden  in  the 
recess  of  a  natural  fold.  The  removal  of  stitches 
or  clamps  can,  of  course,  be  altogether  circum- 
vented, by  using  a  properly  chromicized  catgut  fila- 
ment. No.  000  catgut  of  40-day  resistance  will  be 
absorbed  in  due  time,  that  is,  approximately  in  five 
to  twelve  days.  The  subcuticular  suture,  or  zinc 
oxide  adhesive  strips,  are  not  as  practicable  in  clos- 
ing this  incision  as  they  might  perhaps  seem  to  be. 
The  subcuticular  suture  is  difficult  to  apply  to  any 
semicircular  flap  without  obtaining  an  uneven  ap- 
position, while  sterile  zinc  oxide  strips  are  apt  to 
adhere  imperfectly,  and  become  detached  subse- 
quently under  the  influence  of  the  sebaceous  secre- 
tion, together  with  the  traction  exerted  upon  the 
wound  when  the  patient  awakes. 

The  prime  object  of  incisions,  to  gain  satisfactory 
exposure,  may  be  sacrificed  unwittingly  when  im- 
portant accessories  are  overlooked.  In  a  pelvic 
operation  the  surgeon  may  be  struggling  to  get  the 
intestines  out  of  the  field  and  the  pelvic  organs  into 
better  view;  he  may  criticise  the  incision,  the  re- 
traction by  his  assistants,  or  his  anesthetist  for  in- 
sufficient relaxation,  while  he  is  totally  unconscious 
of  the  fact  that  the  patient  has  not  been  put  into 
Posture  *^^  proper  Trendelenburg  posture  which  allows  the 
intestines  to  gravitate  towards  the  diaphragm, 
while  the  pelvic  viscera  prolapse  into  the  wound. 
Similarly,  the  reverse  posture  may  be  helpful,  or 


Correct 


Guiding  Principles  in  Surgical  Practice      95 


an  inclination  of  the  patient's  body  to  the  right,  or 
to  the  left  during  an  operation. 

In  the  greater  number  of  conditions  which  the 
surgeon  has  to  deal  with  in  the  lower  abdomen  and 
pelvis,  particularly  in  the  female  patient,  satisfactory 
access  is  afforded  by  the  semilunar  hypogastric 
incision,  and  its  increased  complexity  need  not  be 
in  the  way  of  its  choice.  However,  when  the  time 
involved,  is  a  very  important  factor  a  less  intricate 
method  of  opening  the  lower  abdomen  may  be 
legitimately  employed.  The  simple  median  vertical 
incision,  which  violates  nearly  all  of  the  principles 
that  are  important  in  reparable  incisions,  may  be 
the  only  alternative.  This  technic  may,  however,  be 
very  much  improved  in  a  simple  manner,  if  the 
opening  into  the  fascia  is  made  somewhat  extra- 
median,  so  that  the  tongue  and  groove  principle  in- 
dicated by  Frederic  Kammerer  in  his  right  rectus 
incision,  can  be  applied.  After  section  of  the  skin 
and  subcutaneous  fatty  tissue  in  a  vertical  line  par- 
allel to  the  midline  of  the  abdomen  and  about  one 
inch  to  the  left  of  it,  the  anterior  lamella  of  the  rec- 
tus sheath  is  split  in  the  same  direction.  By  blunt 
dissection  the  mesial  border  of  the  rectus  muscle  is 
defined.  After  retracting  it,  the  posterior  lamella 
is  cut  in  a  line  corresponding  to  the  skin  incision, 
without  injtiring  the  deep  epigastric  vessels.  There 
is  thus  obtained  a  tongue  and  groove  arrangement 
of  the  important  fascial  and  muscular  strata.  The 
tongue  is  represented  by  the  border  of  the  rectus 
muscle,  which  fits  into  the  groove  formed  by  the 
mesial  part  of  the  anterior  and  posterior  lamellae 
of  the  rectus  sheath.  When  this  incision  is  made 
over  the  lowest  one-fourth  of  the  rectus  muscle, 
where  the  posterior  lamella  is  deficient,  the  poste- 


Other 

Methods  of 
Opening  the 
Lower 
Abdomen 


The  Mesial 

Rectus 

Incision 


96      Guiding  Principles  in  Surgical  Practice 

rior  lip  of  the  groove  which  receives  the  rectus  is 
represented  only  by  the  transversalis  fascia  and 
peritoneum.  When  a  longer  incision  is  necessary 
which  extends  beyond  the  level  of  the  fold  of  Doug- 
las, the  posterior  lip  in  the  upper  part  of  the  inci- 
sion becomes  a  more  massive  structure.  There  can 
be  little  doubt  that  the  contractile  muscle  placed  be- 
hind divided  fascial  and  aponeurotic  layers  in  this 
incision,  is  helpful  in  preventing  postoperative  her- 
nia. 
Deep  In  order  to  avoid  injuring  the  deep  epigastric 
Epigastric  artery  needlessly,  by  encroaching  upon  it  while 
extending  the  division  of  the  posterior  lamella  up- 
ward, its  general  course  can  be  traced  out  roughly 
by  a  line  drawn  from  the  midpoint  of  Poupart's 
ligament  to  the  umbilicus. 
Lineae  'pj^g  development,  number  or  absence  of  the  lineae 
transversae,  is  also  of  some  significance.  Along  the 
lineae  transversae  the  anterior  lamellae  of  the  rectus 
sheath — but  not  the  posterior — may  be  quite  ad- 
herent, so  that  it  may  be  impracticable  to  attempt 
dissecting  around  the  border  by  the  blunt  method. 
In  these  cases  the  knife-blade  must  be  used  to  free 
the  muscle.  Usually  such  an  intersection  is  found  at 
the  level  of  the  xiphoid  process,  another  near  the 
umbilicus,  and  one  about  midway  between  these  two 
points.  Sometimes  one  occurs  below  the  umbilicus, 
between  it  and  the  pubic  symphysis.  Although  the 
technic  of  the  incision  is  somewhat  encumbered  by 
the  presence  of  these  tendinous  intersections,  they 
facilitate  the  secure  suture  of  the  rectus  to  the 
bottom  of  the  groove  when  the  wound  is  closed. 

In  the  lower  abdomen  such  an  incision  might  be 
substituted  for  the  semilunar  hypogastric,  in  case 
of  tumors  which  are  so  large  that  they  cannot  be 


Guiding  Principles  in  Surgical  Practice      97 


delivered  through  the  maximum  opening  obtained 
by  the  former  procedure.  For  instance,  when  a 
fibroid  tumor  or  an  ovarian  cyst  reaches  the  um- 
bilical level  or  extends  beyond  it.  It  may  also  be 
in  place,  when  a  large  pus  focus  has  to  be  dealt 
with,  or  in  an  operation  for  advanced  cancer,  or 
finally,  when  the  patient's  vitality  is  low,  the  case 
is  urgent,  and  time  becomes  a  more  important  factor. 

The  method  which  I  have  outlined,  may  be  ap- 
propriately designated,  the  mesial  rectus  incision,  to 
distinguish  from  the  lateral  rectus  incision  in  which 
the  lateral,  not  the  mesial,  margin  of  the  rectus 
muscle  has  to  be  retracted.  In  the  lateral  rectus 
incision,  both  retraction  and  extension  of  the  in- 
cision are  anatomically  limited — the  former  because 
of  the  liability  of  injuring  the  dorsal  nerves  as  they 
enter  the  lateral  border  of  the  muscle  to  supply  it, 
the  latter,  because  these  nerves  cross  the  path  of 
the  incision. 

The  principles  which  are  apparent  in  the  analysis 
of  routine  incisions  in  the  lower  abdomen,  are,  in 
general,  valid  when  the  parietal  route  through  the 
upper  abdomen  is  chosen.  Similarly,  a  routine  in- 
cision in  this  region  must  be  so  outlined  that  it  will 
suffice  for  the  thorough  examination  of  the  gall- 
bladder and  ducts,  pancreas,  stomach  and  duodenum ; 
it  should  be  capable  of  such  extension  as  operations 
on  these  organs  may  necessitate.  The  posture  of 
the  patient  is  here  also  none  the  less  vital,  particu- 
larly for  the  proper  presentation  at  the  wound  of 
those  organs,  which  lie  close  to  the  vault  of  the 
diaphragm,  or,  in  overcoming  difficulties  when  the 
incision  is  small,  or  unfavorably  situated. 

In  place  of  the  routine  incision,  a  number  of 
special  incisions  into  the  abdominal  wall,  have  been 


Indications 
for  the 
Incision 


The   Mesial 
Rectus 
Incision 
not    the 
Lateral 


Routine 
Incisions 
in  the  Upper 
Abdomen 


98      Guiding  Principles  in  Surgical  Practice 

devised  by  various  surgeons  for  exceptional  cases. 
They  are  indicated,  when  extension  of  the  incision, 
or  exploration  is  not  deemed  necessary.  It  is  a  good 
rule  to  make  use  of  such  an  incision  only,  when  it 
is  unlikely  that  there  is  an  error  in  the  diagnosis. 
An  exception  may  sometimes  be  made,  when  the 
surgeon  has  before  him  a  sudden,  severe,  acute 
abdominal  condition,  which  demands  surgical  in- 
vestigation at  once,  before  he  can  decide  whether 
the  trouble  is  located  in  the  upper  or  lower  half  of 
Special  ^he  abdomen.  An  acute  appendicitis  is  naturally 
to  be  considered  first  because  of  its  relative  fre- 
quency, and  a  Kammerer  right  rectus  incision  or  a 
small  McBurney  incision  in  the  right  iliac  region 
may  be  made  with  this  in  view.  In  order  to  meet 
complications  arising  from  errors  in  the  diagnosis 
of  chronic  appendicitis,  and  to  facilitate  dealing 
with  the  surgical  conditions  which  may  simulate 
this  trouble,  Robert  F.  Weir  suggested  his  method 
of  extending  the  McBurney  intermuscular  incision. 
Again,  when  chronic  appendicitis  occurs  together 
with  a  right  inguinal  hernia,  both  may  be  attacked 
through  a  single  skin  incision.  Such  a  technic  was 
described  by  Franz  Torek  (Annals  of  Surgery, 
May,  1906),  and  also,  in  one  of  my  cases,  which 
presented  some  complications,  by  A.  H.  Harrigan 
(The  Combined  Operation  for  the  Radical  Cure  of 
Inguinal  Hernia  and  Appendicitis,  Medical  Record, 
June  26,  1909). 

Before  he  approaches  the  operation,  the  surgeon 
should  have  a  definite  plan  of  procedure  which  is 
not  based  on  ther  observation  of  others,  but  on  his 
own  critical  analysis  of  the  case.  The  chief  com- 
plaint of  the  patient,  that  for  which  relief  is  sought, 
the  best  route  of  attack;  the  possible  error  in  diag- 


Guiding  Principles  in  Surgical  Practice      99 

nosis,  and  the  complications  in  the  surgical  technic 
which  this  may  involve;  all,  must  have  been  con- 
sidered beforehand.  Whenever  an  exact  diagnosis 
cannot  be  made,  the  incision  assumes  an  exploratory 
character.  A  small  incision  can  be  widened,  or  Choice  of 
readily  closed,  and  a  second  incision  made  in  a  more  Incision 
favorable  situation,  when  the  real  nature  of  the 
trouble  is  revealed.  Thus,  in  a  patient  who  has  had 
a  slight  rise  in  temperature  for  some  time  previous 
to  her  operation,  if  a  retroperitoneal  tumor  con- 
nected with  the  kidney  is  discovered,  on  account  of 
the  greater  safety,  good  surgical  judgment  may 
demand  the  selection  of  the  retroperitoneal  route 
through  a  lumbar,  instead  of  a  ventral  incision. 

At  the  present  day,  when  so  much  has  been  done 
to  make  surgery  an  exact  procedure,  the  various 
modes  of  gaining  access  to  the  site  of  disease  in  the 
human  body,  deserve  critical  consideration.  It  is 
not  always  the  simplest  technic,  which  is  at  the  same 
time  the  most  conservative,  and  the  best.  Important 
details  in  a  method,  cannot  conscientiously  be  dis- 
regarded in  the  effort  to  attain  unwarranted  speed. 
An  operation  may  be  quickly  ended,  it  takes  longer 
to  complete  it,  still  longer  to  finish  it. 


CHAPTER  X 


The  Course  of  the  Operation 


Division  of 
Labor 


First  and 

Second 

Assistants 


Orderly  procedure  calls  for  the  definite  division 
of  labor  at  an  operation.  It  helps  to  save  time,  and 
to  conserve  the  surgeon's  energy  for  the  more  vital 
phases  of  his  work.  It  is  not  an  easy  matter  to 
train  assistants,  and  to  operate  at  the  same  time. 
However,  it  lies  in  the  nature  of  every-day  practice, 
that  men  unacquainted  with  each  other's  peculiari- 
ties, occasionally  have  to  work  together.  In  general, 
there  ought  to  be  a  clear  understanding  beforehand, 
about  the  division  of  labor  at  the  operation.  The 
surgeon  who  makes  the  plan  for  treatment  and 
executes  the  operation,  at  once  assumes  the  un- 
divided responsibility  for  the  physical  well-being  of 
his  patient;  and  whatever  be  the  individual  plan  in 
the  work  assigned  to  those  who  help  him,  it  must 
necessarily  be  subservient  to  his  own. 

The  surgical  assistant  exposes  the  structures  so 
as  to  make  them  accessible,  and  assists  the  operator 
directly  at  every  step.  When  it  becomes  necessary 
to  retain  exposure  for  a  longer  period,  a  second 
assistant,  or  in  his  absence,  the  nurse  at  the  instru- 
ment table,  assumes  this  function.  Thus,  the  first 
assistant's  hands  are  left  free  to  work  with  the 
surgeon.  In  operations  on  the  spine,  or  in  trans- 
thoracic surgery,  where  the  interfering  structures 
are  relatively  inelastic  and  rigid,  it  may  be  practical 
to  substitute  self-retaining  retractors  for  one  of  the 
assistants,  but  in  most  cases  there  is  no  device,  which 
can  hold  or  guide  the  retractor  as  well  as  the  human 
hand. 

(100) 


Guiding  Principles  in  Surgical  Practice     101 

Since  the  plan  of  procedure  is  properly  formu- 
lated by  the  surgeon  on  whom  all  the  responsibility 
for  the  success  or  failure  of  the  undertaking  de-  Assistant's 
volves,  the  assistant  should  not  consider  it  within  Function 
his  sphere,  to  suggest.  Sometimes  there  are  brief 
periods  of  relaxation  during  a  tedious  operation 
when  the  surgeon  ceases,  for  the  moment,  to  ex- 
ercise his  critical  judgment  in  the  usual  way.  Per- 
haps he  has  been  under  a  continued  strain  from 
previous  cases,  or  is  exhausted  in  body  and  mind 
from  night-work  and  lack  of  sleep.  At  such  a  junc- 
ture, he  may  spontaneously  give  expression  to  his 
indecision,  and  a  mature  assistant  may  do  much  to 
aid  him.  Notwithstanding  this,  it  is  an  impress  of 
good  training,  to  offer  no  suggestions,  however 
tempting  the  situation  may  be,  unless  these  are 
solicited,  and  then  only  with  the  greatest  caution 
and  reserve.  Of  all  concerned  in  the  operation,  it 
is  the  surgeon  pre-eminently,  whose  conception  of 
the  condition  which  presents  itself,  is  apt  to  be  the 
most  profound,  and  who,  while  executing  the  work, 
alone  is  in  a  position  to  follow  every  phase  of  the 
situation.  It  is  for  him,  therefore,  and  not  for  his 
assistants,  to  decide,  what  is  to  be  done  at  a  critical 
turn.  Indeed,  the  psychology — the  mental  processes 
— during  an  operation  ought  to  be  of  practical  in- 
terest. Most  of  us  have  experienced,  that  in  a  time 
of  indecision,  the  mind  may  be  unduly  receptive  to 
an  extraneous  idea — a  plan  is  quickly  adopted  with- 
out passing  the  usual  muster.  When  the  operation 
is  over,  an  afterthought  brings  with  it  the  realiza- 
tion that  an  error  in  judgment  has  been  made'. 

The  experienced  operating-room  nurse,  in  a 
measure,  anticipates  the  surgeon.  Needles  are 
threaded  beforehand,  and  the  instruments  are  ar- 


102    Guiding  Principles  in  Surgical  Practice 


Function 

of  the 

Operating 

Room  Nurse 


ranged  on  the  instrument  table  according  to  some 
logical  scheme  to  which  she  has  accustomed  herself. 
For  instance,  she  may  separate  into  groups, 

( 1 )  Instruments  for  the  grasping  of  structures, 
and  exposure  of  the  field;  tissue  forceps,  tenacula, 
volsella,  retractors. 

(2)  Instruments  for  the  cutting  or  division  of 
tissues;  scalpels,  scissors,  saws,  bone  chisels  and 
mallet,  rongeur  forceps. 

(3)  Instruments  for  the  clamping  of  blood  ves- 
sels, or  hollow  organs;  hemostatics,  clamps  for  the 
broad  ligament,  stomach,  bowel. 

(4)  Instruments  for  tissue-repair;  needles, 
needle-holders,  and  suture  material;  Michel's  skin 
clamps;  drills  and  wire;  Lane's  plates. 

It  is  the  technical  part  of  the  operation  which 
consists  of  exposing,  cutting,  clamping  and  repair- 
ing, to  which  her  attention  is  directed.  She  groups 
the  acts  of  the  surgeon  under  these  headings,  as  she 
selects  the  instruments  which  are  to  be  held  in  readi- 
ness for  a  particular  step.  Thus,  for  example,  the 
initial  incision  is  preceded  by  draping  and  the  ap- 
plication of  towel  clamps;  then  come  a  scalpel  and 
two  sharp  retractors.  Bleeding  which  follows,  de- 
mands sponges  and  hemostatics;  subsequently,  cat- 
gut and  scissors.  In  this  way,  each  act  of  the 
surgeon  throughout  the  operation,  evokes  on  her 
part,  a  well-directed  response.  The  instruments 
which  are  immediately  necessary  are  kept  on  the 
Hartley  table  within  his  easy  reach,  and  those  which 
become  unnecessary  are  promptly  removed. 

The  family  physician  is  often  present  at  the  opera- 
tion. His  correct  function,  is  not  that  of  a  surgical 
assistant,  but  more  properly  that  of  a  medical  con- 
sultant.    In  this  capacity,  he  moves  in  his  natural 


Guiding  Principles  in  Surgical  Practice     103 

sphere  of  usefulness,  and  is  thoroughly  uncon- 
strained. His  concrete  impressions  of  the  chief  com-  j,^^  Family 
plaints  of  his  patient,  his  accurate  knowledge  of  her  Physician 
debilities,  idiosyncrasies,  and  her  recuperative 
powers  under  various  conditions,  the  effect  of  pre- 
vious operations,  all  may  be  of  value  to  the  surgeon 
in  determining  his  plan.  The  presence  of  many 
consultants,  on  the  other  hand,  should  scarcely  ever 
be  indicated.  Many  of  us  have  seen  this  prove  to 
be  an  embarrassing  complication.  The  extraneous 
influences  which  are  thus  added,  serve  merely  to 
distract  the  surgeon,  and  may,  to  the  patient's  dis- 
advantage, sway  him  from  his  wonted  course.  Be- 
sides, opinions  differ  in  regard  to  details  of  personal 
experience;  many  consultants  are  like  many  clocks 
— they  are  apt  to  disagree. 

In  dividing  tissues  and  separating  structures  from 
each  other  during  an  operation,  it  is  not  to  be  over- 
looked that  the  more  extensive  the  surgical  trauma 
which  has  been  inflicted,  the  greater  will  be  the  de- 
mand upon  the  organism  in  the  subsequent  process 
of  healing.  When  the  separation  of  layers,  or  the 
isolation  of  vessels,  nerves  and  other  structures  can 
be  avoided,  it  is  usually  in  point  to  do  so.  In  this 
sense,  a  good  dissection  may  become  a  faulty  opera-  Avoidance  of 
tion.  The  principle  applies  to  numerous  operations  Dissection 
which  are  commonly  practised.  In  the  case  of  an 
inguinal  hernia  in  the  male  subject,  demonstration 
of  the  individual  structures  of  the  cord  by  dissection, 
except  in  so  far  as  the  technic  of  the  hemioplasty 
absolutely  requires  it,  is  of  questionable  value. 
Similarly,  it  is  a  decided  technical  error  to  isolate 
the  ureter  needlessly  from  its  bed,  in  operation  in 
its  vicinity.  In  general,  the  extensive  freeing  and 
demonstration  of  vessels  and  nerves,  is  not  in  strict 


104     Guiding  Principles  in  Surgical  Practice 


Safe 
Hemostasis 


Difficulty 

Due  to 

Bowel 

Distension 


The 

Embracing 

Forceps 


-  accord  with  the  fundamentals  of  conservative  sur- 
gery; the  healing  process  invariably  calls  for  some 
scar-formation  about  these  delicate  organs,  which 
may  ultimately  lead  to  constriction  or  impairment 
of  their  nutrition. 

When  a  deep  blood  vessel  has  to  be  tied,  it  is  a 
simple  matter  to  transfix  the  suture.  This  precau- 
tion ought  always  to  be  taken  against  the  possible 
slipping  or  dislodgment  of  such  a  ligature.  Tying 
vessels  en  masse,  is  unsurgical ;  the  hemostasis  is 
imperfect,  the  grasp  of  the  ligature  insecure.  Thus, 
many  accidents  from  postoperative  hemorrhage  have 
at  one  time  followed  the  employment  of  Tait's  fig- 
ure-of-eight knot,  in  salpingo-oophorectomy. 

Marked  bowel  distention  may  prove  to  be  quite 
an  encumbrance,  on  account  of  its  interference  with 
retraction  and  exposure.  It  occurs  not  only  in  peri- 
tonitis, that  is,  in  inflammatory  conditions,  but  as 
well,  without  actual  inflammation,  for  example,  after 
internal  hemorrhage.  Of  course,  no  effort  on  the 
part  of  the  anesthetist  will  relieve  the  difficulty.  It 
calls  for  adequate  posture  of  the  patient,  and  careful 
walling-off  of  the  bowel  to  prevent  its  continual  pro- 
lapse into  the  wound. 

Retraction  should  always  be  gentle  and  elastic. 
Organs  like  the  brain  or  liver  require  particular  care. 
Nerves  should  not  be  caught  with  the  ordinary 
thumb-forceps,  but  cautiously  drawn  aside  by  means 
of  a  small  hook,  or  lifted  out  of  the  way  with  a 
small  thumb-forceps  with  thin  blades  which  are 
bent  slightly  at  the  end  so  that  the  structure  can  be 
picked  up  without*  contusing  it — embracing-f creeps. 

Finally,  surgical  wounds  which  have  been  in- 
flicted, must  be  repaired.  The  needle  which  is 
most  universally  useful  is  curved;  its  curve  corres- 


Guiding  Principles  in  Surgical  Practice     105 

ponds  to  one-half  of  a  circle.  Its  size  might  be 
rationally  indicated  by  the  length  of  its  cord,  in  other  Choice  of 
words,  the  distance  between  the  point  and  the  eye.  Needles 
Since  much  of  the  work  in  surgery  has  to  be  exe- 
cuted within  narrow  confines,  a  needle  with  a  shal- 
low curve,  for  instance,  a  quarter-circle,  or  less 
still,  a  straight  needle,  is  awkward  to  introduce  and 
to  deliver,  during  the  application  of  the  suture.  The 
path  traversed  by  the  semicircular  needle,  on  the 
contrary,  corresponds  to  the  natural  turn  of  the 
hand  and  wrist,  and  the  point  enters  the  tissue- 
planes  and  emerges  from  them  in  a  vertical  direc- 
tion. 

Whether  the  needle  in  a  particular  case  is  to  be 
round-bodied,  or  whether  it  should  have  a  cutting 
edge,  depends  on  the  nature  of  the  structures  to  be 
united.  If  one  were  guided  by  theoretical  considera- 
tions alone,  the  round-bodied  needle  might  be  given 
the  preference,  because,  where  it  can  be  used,  it 
appears  to  subject  the  tissues  to  the  smallest  amount 
of  traumatism;  it  penetrates  by  separating,  rather 
than  by  cutting  them.  In  practice,  however,  there 
are  salient  objections  to  it.  Round-bodied  needles 
can  be  carried  through  dense  structures  only  with 
considerable  difficulty,  and  often  at  the  risk  of  break- 
ing the  needle.  Besides,  there  is  the  additional  dis- 
advantage that  the  smooth,  round  body  easily  rotates 
within  the  jaws  of  the  needle-holder,  unless  the  lat- 
ter is  supplied  with  a  catch.  The  usefulness  of 
round-bodied  needles,  on  this  account,  extends  but 
rarely  beyond  the  repair  of  surgical  wounds  of  the 
stomach  or  bowel,  or  of  a  tear  or  cut  in  a  parenchy- 
matous organ.  For  the  great  mass  of  plastic  surgery, 
it  is  best  to  select  needles  with  a  cutting  edge.  Pro- 
bably the  most  generally  useful  of  all,  in  surgical 


106    Guiding  Principles  in  Surgical  Practice 

routine,  are  those  which  are  quadrangular  towards 
the  eye  where  the  needle-holder  grasps  them,  but 
triangular,  with  a  cutting  edge  and  bayonet  point, 
in  the  engaging  portion — semicircular  needles  with 
bayonet  points.  The  so-called  sinus  needles  have 
flat  bodies ;  they  slit  the  tissues  easily  and  are  readily 
broken  during  sewing  manoeuvres,  because  the 
strain  is  directed  against  the  shorter  and  weaker  axis 
of  their  bodies.  Conversely,  the  curved  Hagedorn 
needle  is  flattened  from  side  to  side,  the  longer  axis 
of  its  body  is  sufficient  to  resist  the  bending  strain 
put  upon  it  in  suturing,  so  that  it  is  seldom  broken, 
but  it  is  not  well  adapted  for  use  in  a  plain  needle- 
holder. 

Special  needles  are  the  long  straight  needles  with 
a  round  body,  which  are  useful  for  suturing  the 
stomach  or  bowel,  whenever  these  organs  can  be 
lifted  up  into  the  wound,  so  as  to  obtain  ample 
working-room.  Such  needles  are  manipulated  by 
the  fingers  in  the  manner  of  the  seamstress,  without 
the  aid  of  a  needle-holder.  Furthermore,  for  the 
anastomosis  of  blood  vessels,  some  technicians  pre- 
fer to  use  a  "half-curved"  needle — a  straight  needle 
with  a  curved  point.  The  curved  end  facilitates  the 
engagement  and  delivery  of  the  point,  while,  with 
some  practice,  the  straight  end  makes  dexterous 
manipulation  possible  without  the  aid  of  a  needle- 
holder. 

While  working  in  the  peritoneal  cavity,  the  best 
prophylaxis  against  general  contamination  of  the 
peritoneum,  consists  in  the  thorough  walling-oflf  of 
Walling-off  a  the  suspicious  focus  by  means  of  gauze.  Should  an 
Pus  Focus  effusion  of  septic  material  take  place,  its  escape  into 
the  peritoneal  cavity  is  efifectually  barred.  Small 
sponges  ought  rarely  to  be  used;  when  a  strip  of 


Guiding  Principles  in  Surgical  Practice     107 


gauze  cannot  replace  them,  they  should  be  fed  to  the 
forceps  by  the  nurse,  one  by  one,  so  that  two  of 
them  cannot  be  picked  up  at  once,  the  one  being  re- 
turned, while  the  other  is  lost  in  the  wound. 

Bacteria  may  be  carried  from  the  skin  to  the 
deeper  layers,  but  cannot  readily  form  colonies  in 
contact  with  the  healthy  living  tissue.  In  stagnating 
fluids,  when  proper  tissue  apposition  is  neglected, 
and  so-called  "dead  spaces"  are  left  in  the  wound, 
there  are,  however,  presented  all  the  conditions  fa- 
vorable to  their  growth.  It  is,  because  blood  and 
tissue-lymph  are  excellent  culture  media  for  path- 
ogenic organisms,  that  their  accumulation  in  heal- 
ing wounds  should  be  scrupulously  avoided.  This 
is  why,  in  wounds  of  the  abdominal  wall,  when  the 
panniculus  adiposus  is  well  developed,  gaps  in  the 
fatty  layer  must  always  be  closed.  For  similar  rea- 
sons, after  radical  operation  for  cancer  of  the  breast, 
a  drain  is  inserted  into  the  most  dependent  portion  of 
the  axilla,  when  the  pyramidal  space  which  is  left 
after  operation  cannot  be  obliterated  by  suture,  or 
by  the  use  of  an  axillary  pad.  In  inguinal  and 
femoral  herniae,  drains  are  no  longer  used,  because 
the  spica,  when  snugly  applied,  efficiently  coapts  the 
fascial  strata. 

The  session  in  the  operating  theatre  may  bring 
with  it  untoward  events.  An  occurrence  such  as  the 
fainting  of  a  nurse  or  an  assistant  should  not  be 
allowed  to  upset  the  strict  regime.  It  is  unwise, 
especially  for  a  novice,  to  attempt  the  strenuous  task 
which  an  operation  imposes  on  every  one  concerned, 
with  a  fasting  stomach  or  a  considerable  burden  of 
clothes.  If  one  of  those  in  attendance  requires  at- 
tention, this  should  be  given  without,  at  the  same 
time,  violating  the  asepsis.    In  complications,  in  the 


Fluid 

Collections 
and  Dead 
Spaces 


Fainting  of  a 
Nurse 


108    Guiding  Principles  in  Surgical  Practice 


Collapse 

of  the 

Patient 


Hemorrhage 


course  of  the  anesthesia,  such  as  collapse,  be  it 
cardiac  or  respiratory,  the  first  thought  is  always  to 
rid  the  patient  of  the  residual  anesthetic  by  prompt 
artificial  respiration,  while  the  surgeon  protects  the 
operating  field  with  a  sterile  towel.  The  manipula- 
tions are  executed  by  grasping  both  forearms  of  the 
patient  near  the  elbow,  and  extending  them  over  the 
head.  After  a  brief  pause,  they  are  again  returned 
to  the  side  of  the  chest  to  produce  a  forcible  ex- 
piration. This  should  be  done  rhythmically,  and  at 
about  the  rate  of  natural  breathing.  The  anesthetist 
must  see  that  the  tongue  is  forward,  and  no  impedi- 
ment exists  in  the  upper  air-passages. 

A  large  vessel  may  be  cut  or  torn  while  operating. 
The  pedicle  of  the  right  kidney  is  rather  short  and 
easily  injured  while  delivering  the  organ  through  a 
lumbar  incision.  A  profuse  hemorrhage  may  occur 
from  the  renal  vein,  the  wound  is  at  once  flooded 
with  blood,  so  that  nothing  can  be  seen.  Counter- 
pressure  with  the  hand  from  the  front,  and  a  large 
tampon  of  gauze  packed  tightly  into  the  bottom  of 
the  wound,  may  be  the  only  alternative.  An  intra- 
venous infusion  of  physiological  saline  may  have  to 
be  immediately  started,  and  little  or  no  anesthetic 
must  be  administered  for  the  time  being. 

Generally  speaking,  death  during  a  serious  opera- 
tion in  an  enfeebled  patient,  is  not  sudden,  but 
gradual.  The  anesthetist  discovers  the  progressive 
failing  in  vitality,  and  such  an  indication  should  be 
promptly  announced.  Sudden  death  during  opera- 
tions, however,  may  occasionally  occur,  for  instance, 
as  the  result  of  air  embolism.  The  aspiration  of 
air  is  most  likely  to  take  place  through  wounds 
in  the  larger  venous  trunks  in  the  proximity  of  the 
heart,  because,  in  these,  during  the  act  of  inspira- 


Guiding  Principles  in  Surgical  Practice     109 

tion,  the  pressure  becomes  decidedly  negative. 
Sometimes  indeed,  the  aspiration  of  air  is  followed  ^^^ 
by  dilation  of  the  pupil  and  the  breathing  becomes  "^  °  *^™ 
labored,  but  the  patient  subsequently  recovers.  At 
all  events,  in  such  an  emergency,  the  first  thought 
is  compression  of  the  vein  at  the  site  of  the  injury, 
or  on  the  heart-side  of  it,  to  prevent  further  aspira- 
tion. Meanwhile,  the  field  is  kept  flooded  with 
saline  until  the  wound  in  the  vein  can  be  closed. 
If  measures,  as  the  forcible  compression  of  the 
chest,  combined  or  uncombined  with  inflation  of  the 
lung  with  oxygen  by  means  of  a  tube  passed  through 
the  patient's  nostril,  are  indicated,  and  are  really  of 
therapeutic  value,  remains  still  to  be  ascertained. 


from  the 
Operating 


CHAPTER  XI 
Care  of  the  Patient  After  Operation 

The  attentive,  kindly  nurse  can  do  much  towards 
minimizing  the  discomfort  of  her  charge.  Many- 
Arrival  patients  sweat  profusely  after  operation,  and  the 
wet  shirt  is  promptly  exchanged  for  a  dry  one,  the 
Room  covers  are  tucked  snugly  over  the  shoulders  and 
chest;  and,  if  the  temperature  of  the  room  is  low, 
or  the  patient's  condition  poor,  hot  water  bags  are 
applied  at  once  to  the  side  of  the  body  and  lower 
extremities.  A  chilling  of  the  surface  may  mean 
suppression  of  the  excretory  skin  activity,  and  ad- 
ditional work  for  the  kidney  which  is  already  over- 
taxed. On  the  other  hand,  bronchial  congestion 
following  neglect,  may  lead  to  pulmonary  complica- 
tions which  might  have  been  avoided. 

After  the  brief  vomiting  which  sometimes  follows 
awakening,  the  comfort  of  a  soft  pillow  under  the 
head,  should  not  be  withheld.  The  abdominal 
wound  may  be  supported  when  the  patient  vomits, 
to  lessen  the  pain  caused  by  this  sudden  impulse ;  a 
pillow  placed  under  the  knees,  reduces  traction  upon 
the  suture.  The  patient's  mouth  is  rinsed  with  lime- 
water  or  milk  of  magnesia,  to  remove  the  after-taste 
of  the  anesthetic;  she  may  be  allowed  to  inhale  the 
vapors  from  a  ball  of  cotton  moistened  with  alcohol 
and  acetic  acid.  The  dry  lips  are  kept  moist;  a 
wet  cloth  over  the  forehead  and  eyes,  helps  to 
induce  sleep.  The  cloth  should  not  drip,  nor  should 
water  flowing  from  it  into  the  patient's  ear,  escape 

(110) 


Guiding  Principles  in  Surgical  Practice     111 

notice.  During  the  first  twenty-four  hours  after 
operation,  one  or  two,  or,  if  necessary,  more  doses 
of  morphine  sulphate,  one-quarter  grain  each,  are 
allowed  hypodermatically.  The  first  dose,  is  usually  MQj.„i^in 
given  as  soon  as  the  patient  becomes  restless.  The 
second,  not  sooner  than  four  hours  later,  when 
post-operative  discomfort  reasserts  itself.  Finally, 
on  the  evening  of  the  next  day,  a  third  dose  is 
generally  indicated.  It  is  well  not  to  continue  the 
administration  of  morphine  any  longer  than  is 
necessary.  After  many  abdominal  operations  there 
remains  on  the  second  or  third  day,  little  more 
than  a  soreness  in  the  region  of  the  wound  and  per- 
haps a  dull  ache  in  the  back. 

It  is  important  to  analyze  the  patient's  complaint. 
The  occasional,  migrating  pain  in  the  abdomen,  or 
the  sharp  twinge  that  comes  and  goes,  and  appears 
on  the  second  day  or  later,  is  usually  a  gas  pain. 
It  has  its  origin  in  the  paretic  intestine,  and  not  in  Q^g  p^j^ 
the  wound.  The  simple  peppermint  enema  affords 
relief,  while  morphine  would  be  only  of  transient 
value,  and  is  not  the  logical  remedy.  It  is  the  part 
of  wisdom  to  avoid  promiscuous  medication.  Per- 
sonally, I  believe  that  the  treatment  of  a  surgical 
case  should  be  left  entirely  to  the  surgeon,  all 
orders  being  issued  by  him  until  the  patient  is  in 
a  condition  to  be  dismissed  from  his  care. 

Unnecessary  division  of  responsibility  leads  to  a 
division  of  the  plan  of  treatment,  complicating  in- 
structions to  the  nurses,  and  is  not  for  the  best 
interest  of  the  patient.  Frequently,  the  surgeon's 
lack  of  knowledge  of  the  dosage  and  action  of  drugs, 
has  helped  in  this  regrettable  complication.  It  is 
rare  indeed,  that  a  drug  is  imperative  in  a  surgical 
case,  but  where  one  is  indicated,  he  should  appre- 


112     Guiding  Principles  in  Surgical  Practice 

ciate  the  indication,  and  ought  not  to  be  at  sea  about 

the  exact  dose,  vehicle  and  conditions  necessary  to 

insure  the  desired  effect. 

Axioms  worth  bearing  in  mind,  are  the  following : 
Anodynes 

and        (^)     After   operation,   it   is   well   to    spare   the 

Somnifacients    rebellious  stomach  from  drugs. 

(b)  Morphine  is  primarily  not  a  somnifacient, 
but  an  anodyne,  and  the  patient  sleeps  after  its  use 
because  the  disturbing  pain  has  been  relieved. 

(c)  Veronal,  veronal-sodium,  tetronal,  trional, 
sulphonal,  and  allies,  on  the  other  hand,  are,  strictly 
speaking,  somnifacients  and  not  anodynes.  These 
drugs  therefore,  cannot  replace  morphine  for  post- 
operative use. 

(d)  Of  anodynes  allied  to  morphine,  codeine 
phosphate  and  dionine  are  readily  soluble  in  water, 
and  can  be  given  subcutaneously,  but  the  action  of 
these  is  feeble  when  compared  with  morphine,  and, 
the  instance  in  which  their  postoperative  administra- 
tion might  be  indicated  must  be  exceptional. 

No  sleep  is  as  refreshing,  and  as  beneficial  as  the 
natural  sleep.  After  the  first  few  days  when  the 
meridian  of  pain  has  been  passed,  and  anodynes 
have  no  purpose,  it  seems  to  me  an  error  in  judg- 
ment, to  yield  too  readily  to  the  patient's  request 
for  "something  to  make  her  sleep."  A  patient  who 
Sleep  is  resting  in  bed  all  day  long,  cannot  expect  to  sleep 
as  soundly  throughout  the  night,  as  she  was  wont 
to  do  after  a  da/  of  bodily  activity.  A  nervous 
unrest  produced  by  anticipation  of  stitches  to  be 
removed,  worry  about  the  nature  of  her  operation, 
or  its  ultimate  outcome,  some  home  trouble  carried 


Guiding  Principles  in  Surgical  Practice     113 


into  the  sick-room  by  an  indiscreet  visitor,  a  thou- 
sand little  things,  may  upset  the  delicate  nervous 
mechanism  of  the  patient  and  be  the  cause  of  a 
wakeful  night.  An  artificial  slumber  produced  by 
drugs,  is  not  going  to  be  of  half  so  much  benefit  to 
such  an  individual  as  a  natural  one,  following  per- 
haps a  cold  sponge-bath,  or  a  little  mental  influence. 

The  question  frequently  arises :  How  long  shall 
we  wait  before  catheterizing  a  patient  after  opera- 
tion? In  gynecological  cases  there  is  not  infrequent- 
ly a  reflex  dysuria,  a  reflex  retention  of  urine  which 
disappears  after  the  first  micturition. 

Except  in  those  cases  in  which  the  bladder  had 
to  be  opened  during  the  operation,  and  there  is 
danger  of  leakage,  there  is  no  reason  why  one 
should  order  immediate  catheterization.  The  secre- 
tion of  urine  after  operation  is  naturally  diminished, 
because  the  patient  has  lost  a  great  deal  of  fluid  by 
sweating,  and,  in  addition,  she  is  receiving  very 
little  to  drink.  It  is  therefore  easy  to  understand 
that  twenty-four  hours  may  elapse,  before  the 
bladder  is  really  distended  to  the  point  of  dis- 
comfort, and  then  the  patient  voids  spontaneously 
after  making  a  slight  effort.  Some  patients  cannot 
void  when  there  is  someone  in  their  presence,  but 
are  successful  after  the  nurse  has  left  the  room; 
others  should  have  a  screen  placed  around  the  bed ; 
others  respond  when  they  hear  the  running  of  the 
water  at  the  hydrant;  or  gentle  pressure  over  the 
lower  part  of  the  abdomen  may  start  urination,  or 
a  cold  application  to  the  inside  of  the  thigh,  or  .water 
from  a  sponge  trickling  over  the  vulva,  or  gentle 
vibration  or  Faradization  of  the  hypogastrium.  It 
may  happen  that  the  initial  difficulty  is  overcome 
after  receiving  an  enema.    Some  patients,  however, 


Catheterization 


Dysuria 


114    Guiding  Principles  in  Surgical  Practice 

defy  every  expedient  and  have  to  be  catheterized 
regularly,  until  the  moment  arrives,  when  they  are 
allowed  to  sit  up ;  and  then,  voiding  occurs,  without 
any  difficulty  whatever.  Where  catheterization  is 
necessary,  it  should  be  done  as  infrequently  as  pos- 
sible; once  every  eight  hours  is,  as  a  rule,  sufficient. 
The  vulva  and  meatus  urethrae  are  rinsed  with  a 
little  warm,  two  per  cent,  boric  acid  solution;  and 
the  catheterization  is  done  aseptically  and  gently. 
In  the  first  days  after  operation  it  is  of  importance 
to  note  the  quantity  of  urine,  but  the  specimen  itself 
is  often  of  little  value  for  analysis  until  the  first 
Record  of  five  days  have  elapsed.  The  reason  is,  that  post- 
Urine  operative  casts  may  appear  in  the  urine  for  that 
length  of  time,  and  no  reliable  opinion  of  the  normal 
condition  of  the  kidney  can  be  formed  from  such 
analyses.  The  analysis  which  tells  us  this,  is  the 
one  made  of  an  average  specimen  of  urine  taken 
before  operation.  When  a  routine  analysis  is  de- 
sired after  operation,  the  specimen  should  be  col- 
lected after  the  fifth  day.  It  is,  of  course,  most 
accurate  to  obtain  a  sample  of  all  the  urine  voided 
in  twenty-four  hours,  that  is,  a  twenty-four  hour 
specimen.  Where  more  extensive  quantitative  an- 
alyses are  expected,  this  should  always  be  done. 
But,  in  practice,  it  is  much  more  convenient  and 
ordinarily  sufficiently  accurate,  to  take  equal  parts 
of  urine  voided  in  the  morning  and  evening,  and 
mix  the  two  samples  to  obtain,  what  might  be 
called,  an  average  specimen. 

For  a  period  extending  from  three  to  five  days 
after  operation,  the  total  quantity  of  urine  voided 
by  the  patient  should  be  recorded  by  the  nurse. 
Suppression  of  urine  is  an  ocacsional  cause  of 
death  after  operation,  and  any  suspicion  in  this 


Guiding  Principles  in  Surgical  Practice     115 


regard  demands  prompt  and  serious  consideration. 
If  the  suspicion  is  verified,  potent  eliminative  treat- 
ment has  to  be  instituted,  chiefly,  I  think,  by  stimu- 
lating the  excretory  function  of  the  skin  and  the 
bowel  surface.  Hot  bland  drinks  and  a  hot  rectal 
infusion  are  quickly  given,  and  the  patient  is  packed 
in  hot  blankets  until  she  begins  to  perspire  pro- 
fusely. This  procedure,  simple  as  it  is,  and  old  as 
the  history  of  medicine,  is  nevertheless  sometimes 
life-saving  in  its  significance. 

The  usefulness  of  drugs  in  such  cases  is  limited; 
whether  it  is  really  an  advantage  to  administer  pilo- 
carpine and  similar  diaphoretics  in  conjunction  with 
the  physical  treatment,  remains  a  disputed  point. 
Some  other  measures,  for  instance,  the  electric  light 
bed-baths,  on  the  other  hand,  are,  to  my  mind,  fre- 
quently of  invaluable  service  where  these  can  be 
had.  In  some  patients,  at  least,  the  relaxation  which 
follows  the  active  diaphoresis  does  not  seem  to  be 
as  pronounced  after  the  electric  light  bath,  as  it  is 
after  most  other  sweating  measures. 

There  are  probably  as  many  opinions  on  the 
subject  of  postoperative  feeding,  as  there  are  sur- 
geons. I  have  always  believed  in  simple  things, 
and  cherished  the  hypothesis  that  nature  in  her  inner 
workings  is  pre-eminently  simple. 

The  diet  depends,  in  a  great  measure,  on  the  con- 
dition of  the  stomach  after  narcosis.  No  doubt, 
much  can  be  done  towards  minimizing  the  amount 
of  nausea  and  vomiting  after  operation,  by  giving 
adequate  attention  to  certain  seemingly  trifling  de- 
tails. There  should  be  a  proper  understanding  and 
co-operation  between  the  anesthetist  and  the  sur- 
geon. If  the  patient  receives  a  quarter  of  a  grain 
of    morphine   sulphate   hypodermatically,    half    an 


Suppression  of 
Urine 


Postoperative 
Dietetics 


116     Guiding  Principles  in  Surgical  Practice 


Gastric    Upset 

after 

Operation 


Inanition 

before 

Operation 


hour  before  narcosis,  the  anesthetist  allows  by  the 
drop  method  the  minimum  quantity  of  anesthetic 
necessary  to  retain  the  surgical  plane,  and  regulates 
carefully  the  access  of  air  to  the  mask  to  prevent,  at 
any  moment,  undue  concentration  of  the  anesthetic 
vapors,  and  the  symptoms  which  would  arise  from 
crowding  the  anesthetic ;  if  the  surgeon,  mindful  of 
the  real  welfare  of  his  patient,  is  willing  at  times,  to 
suffer  the  inconvenience  of  insufficient  relaxation  of 
the  muscular  wall  of  the  abdomen,  rather  than  urge 
on  his  anesthetist  into  crowding  the  anesthetic,  and 
if  he  will  handle  the  delicate  structures  and  organs, 
especially  the  intestines,  gently  and  as  little  as  pos- 
sible, he  will  have  gained  a  great  deal  towards  at- 
taining this  end.  Some  surgeons  are  unduly  rough 
in  their  manipulations ;  time  seems  to  them  to  be  the 
only  factor,  the  operation  must  be  done  quickly.  But 
naturally,  the  result  after  such  an  onslaught  is  often 
to  be  anticipated;  there  is  much  postoperative  dis- 
tress, vomiting,  gas-pain,  and  a  turbulent  con- 
valescence. 

Another  mistake  that  is  not  infrequently  made, 
is  to  starve  the  patient  before  operation.  With- 
holding food  for  too  long  a  period  before  operation, 
it  strikes  me,  does  not  diminish,  but  rather  helps  to 
increase  the  postoperative  gastric  upset.  The  starv- 
ing body  is  more  readily  poisoned  by  the  anesthetic, 
than  a  well-nourished  one.  All  that  is  required,  as 
a  rule,  is  that  the  stomach  should  be  empty,  at  least 
it  should  not  contain  solid  or  coagulable  food  when 
anesthesia  is  induced.  A  stomach  possessing  nor- 
mal mobility,  should  contain  no  food-remnants  five 
hours  after  the  ingestion  of  a  meal.  In  the  case  of 
gastric  atony,  or  pyloric  stenosis,  the  stomach  might 
have  to  be  washed  to  rid  it  of  stagnating  chyme.    In 


Guiding  Principles  in  Surgical  Practice     117 

practice,  when  the  operation  is  set  for  8  o'clock  in 
the  morning,  the  patient  usually  gets  a  normal  sup- 
per, consisting  of  digestible  food,  on  the  previous 
evening,  and  is  allowed  some  non-coagulable  drink 
in  the  early  morning  hours  if  she  is  awake.  When 
the  operation  is  to  be  at  2  o'clock  in  the  afternoon, 
the  patient  gets  a  good  breakfast,  and  some  non- 
coagulable  drink  at  10.  If  the  patient  has  not  been 
shocked  by  brusque  handling  during  the  operation, 
nor  saturated  with  anesthetic,  she  becomes  con- 
scious promptly,  and  soon  regains  her  natural  tone. 
But  little  nausea  or  vomiting  is  the  rule,  and  five 
or  six  hours  after  operation,  the  nurse  begins  with 
small  quantities  of  liquids,  hot  or  cold,  ranging  from 
a  sip  to  two  fluid  ounces. 

The  liquid  diet  of  the  patient  at  this  period  con- 
sists chiefly  of  water,  hot  or  cold,  weak  tea,  orange-  Liquid  Diet 
ade,  lemonade,  albumen  drinks,  barley-,  oatmeal-  or 
rice-water,  cider  and  other  non-intoxicating  drinks. 
Cow's  milk,  is,  as  a  rule,  objectionable;  it  readily 
forms  large  curds  and  is  difficult  to  digest;  when  it 
is  allowed,  it  should  be  diluted  to  one-half  with 
cereal  water.  The  nurse  begins  the  feeding  cautious- 
ly, and  with  judgment;  it  becomes  her  duty  to  dis- 
cover in  each  case,  what  agrees  best  with  the  patient. 
There  is  no  rule  which  holds  good  for  all.  Some 
patients  have  queer  idiosyncrasies.  Thus,  it  has 
happened  that  a  patient's  stomach  rebelled  against 
everything,  until  she  got  the  draught  of  Pilsener  beer 
for  which  she  had  asked.  In  other  cases,  where  the 
vitality  is  low,  champagne  may  be  given  as  a  stimu- 
lant, and  albumen  drinks  as  a  food.  Sometimes  a 
tumbler  of  lime-water  or  diluted  milk  of  magnesia, 
though  promptly  ejected,  has  a  sedative  action  on 


118    Guiding  Principles  in  Surgical  Practice 

the  stomach  mucous  membrane,  it  seems,  and  makes 

it  more  tolerant  than  before. 

As   soon  as   the  patient  no  longer  experiences 

difficulty  in  retaining  liquids,  generally  twenty-four 

hours  or  so  after  operation,  comes  the  time  when  she 

is  to  be  started  on  her  convalescent  diet,  excepting 

„        ,  this  is,   for  other  reasons,  contra-indicated,  as  in 

Convalescent 

jjigt       some  operations  on  the  stomach  and  bowel,  where 

solid  food  is,  for  the  time  being,  to  be  avoided  for 
purely  mechanical  reasons.  Though  the  patient  at 
this  time  has  but  little  appetite,  she  is  encouraged 
to  take  food.  The  nurse  begins,  for  example,  with 
custard,  or  boiled  rice,  a  piece  of  dry  toast  and  tea, 
or  an  egg,  soft  boiled,  or  poached,  or  even  a  thin 
sandwich  of  scraped  meat.  In  her  selection,  she 
caters  to  the  patient's  preference.  If  these  agree, 
a  piece  of  roast  or  boiled  chicken,  and  then  a  chop 
with  potato  puree  or  milk-rice,  can  safely  follow 
in  the  patient's  menu.  Excess  of  fats  and  sweets 
must  be  avoided.  The  stomach  is  easily  upset  by 
fatty  foods,  while  sweets  are  objectionable  because 
they  have  a  tendency  to  impair  still  more  the  ap- 
petite, which  is  already  diminished. 

The  convalescent  diet  to  which  I  refer,  might  be 
correctly  called  a  light  diet,  inasmuch  as  it  includes 
only  food  which  is  easily  digested  and  does  not 
produce  a  great  deal  of  gas.  "Soft  diet"  is  a  mis- 
leading term  when  used,  as  it  often  is,  to  designate 
a  diet  for  patients  recovering  from  an  operation, 
since  it  is  not  intended  that  the  nurse  should  be 
guided  in  her  seletcion  of  the  patient's  food  by  its 
consistency;  it  is  tlie  digestibility  that  she  must  con- 
sider. In  fact,  many  cheeses  are  soft,  but  very 
hard  indeed  to  digest,  and  no  one  would,  for  a 
moment,  entertain  the  notion  of  including  them  in 


Guiding  Principles  in  Surgical  Practice     119 

what  is  ordinarily  meant  by  a  "soft  diet" ;  the  term 
is  not  significant  except,  if  you  will,  in  the  case  of 
an  individual  who  is  unable  to  masticate  her  food 
properly  because  she  has  lost  her  teeth. 

The  convalescent  diet  list  excludes  cabbage,  and 
leguminous  vegetables  such  as  lima  beans,  beans, 
peas,  lentils,  because  they  are  rather  difficult  to 
digest,  and  produce  an  excessive  amount  of  gas. 
Radishes,  pickles,  Worcestershire  sauce,  mustard 
and  much  spice  should  be  avoided.  Of  fruits, 
bananas  are  not  well  tolerated.  Vinegar,  that  is  the 
acetic  acid  in  it,  is  very  detrimental  to  digestion ; 
the  ordinary  organic  acids  in  fruit,  citric  acid  in 
lemons  for  example,  seem  on  the  contrary  to  have 
a  beneficial  effect.  For  this  reason  may  be  allowed 
lettuce,  water-cress  or  dandelion  prepared  with 
lemon  juice,  but  not  with  vinegar.  In  fact,  these 
leaf  vegetables  appear  to  be  of  certain  value  in 
supplying  in  acceptable  combinations  iron,  sodium 
and  other  inorganic  elements  to  the  system;  the 
human  tissues  do  not  consist  solely  of  proteids,  fats, 
carbohydrates  and  water.  Spinach  too,  belongs  in 
this  category  of  leaf  vegetables;  it  contains  an 
abundance  of  useful  iron  and  other  salts.  It  is, 
however,  essential  to  prepare  it  properly;  that  is, 
with  no  more  water  than  will  steam  off  during  the 
cooking  process.  If  too  much  water  has  been  added, 
and  the  supernatant  liquid  is  decanted,  and  poured 
away  after  cooking,  most  of  the  water-soluble  salts, 
and  other  substances  to  which  the  dish  owes  its 
peculiar  food  value,  are  lost. 

It  is  well  that  the  diet  of  bed-lying  patients  be       Cathartic 
cathartic  in  character.    The  nurse  can  regulate  the       Food 
patient's  bill  of  fare  so  that  some  cathartic  food  or 
drink    is    always    interpolated.      Fresh    fruits,    or 


120     Guiding  Principles  in  Surgical  Practice 

'  Graham  bread  at  breakfast,  or  corn-crisp,  shredded 
wheat,  puffed  rice,  or  other  cereal,  or  stewed  prunes 
or  rhubard ;  or,  after  supper,  a  glass  of  thin  butter- 
milk; all  stimulate  the  sluggish  peristalsis.  On  the 
other  hand,  constipating  foods  such  as  white  bread, 
cake,  strong  tea,  are  restricted,  or  avoided  altogther, 
as  the  case  may  be.  Notwithstanding,  it  is  the 
exception,  especially  among  female  postoperative 
cases,  that  does  not  require  the  aid  of  artificial 
catharsis  or  enemata.  It  is  to  be  anticipated  that 
a  patient  will  tend  to  be  more  constipated  in  bed, 
than  she  was  out  of  bed;  the  great  stimulus  to 
peristalsis  given  by  bodily  activity  is  wanting. 

After  hemorrhoid  operations  and  ano-rectal  plas- 
tics, it  is  merely  necessary  to  restrict  the  patient  to 
a  convalescent  diet  from  which  all  cathartic  foods 
Constipating  j^^^^g  j^^gj^  eliminated,  and  the  almost  uniform  re- 
sult will  be  that  she  remains  constipated  for  five 
days  or  longer.  In  view  of  this  fact,  I  could  never 
fully  understand,  why,  in  such  cases,  the  surgeon 
should  persist  in  the  old  routine  of  giving  opium  by 
mouth.  Besides  this,  even  the  best  of  these  prepara- 
tions, the  deodorized  tincture  of  opium  given  in  a 
little  brandy,  is  liable  to  upset  the  irritable  stomach. 
The  patient  receives  morphine  with  discretion,  but 
as  often  as  she  needs  it  to  make  her  comfortable, 
just  as  in  the  case  of  other  operations.  It  is  always 
given  subcutaneously,  and  in  a  sufficient  dose,  a 
quarter  grain.  Morphine  is  given  hypodermatically 
solely  as  an  anodyne,  not  under  the  impression  that 
it  has  a  material  influence  in  inhibiting  bowel  peri- 
stalsis, as  does  its  ally,  the  crude  drug  opium  when 
administered  in  the  usual  dose  and  manner. 

Furthermore,  in  rectal  cases,  there  is  generally 
not  much  gained  by  allowing  the  bowel  to  remain 


Guiding  Principles  in  Surgical  Practice     121 


inactive  for  a  period  longer  than  five  days.  The 
contents  of  the  large  bowel  Ijecome  so  inspissated 
and  desiccated,  that  ultimately  their  evacuation  is 
accompanied  by  considerable  mechanical  difficulty, 
and  perhaps  damage  to  the  site  of  operation.  In- 
deed in  these  cases,  there  is  less  probability  of 
damaging  the  suture-line  on  the  fourth  or  fifth  day, 
than  later,  when  the  "40-  60-day"  catgut  begins  to 
dissolve.  The  only  reason  for  binding  the  bowels, 
is  in  order  to  keep  the  anorectal  wound  or  suture- 
line  clean,  until  at  least  a  superficial  protective  heal- 
ing has  taken  place,  and  infection  is  unlikely.  This 
is  surely  the  case  after  five  days  have  elapsed.  In 
fact,  if  the  wound-lips  of  the  rectal  mucosa  are 
apposed  with  nicety,  and  this  can  be  best  done  by 
using  a  submucous  suture  of  fine  chromic  catgut, 
000  to  0  in  size,  and  ''40-  60-day"  resistance,  the 
wound  is  superficially,  but  sufficiently  sealed  within 
a  few  days  to  protect  it  quite  well  from  subsequent 
infection,  especially  if  the  bowel  movements  have 
been  loose.  After  the  fifth  day,  the  bowel  evacua- 
tion should  be  anticipated  by  an  oil  and  soap  suds 
enema  given  through  a  well  lubricated  soft  rubber 
rectal  tube.  The  anal  and  rectal  mucosa  covered 
with  an  oily  layer,  is  less  liable  to  be  damaged 
during  the  act  of  defecation. 

The  ideal  cathartic  to  be  given  by  mouth  for 
postoperative  use,  would  be  one  which  is  not  dis- 
agreeable to  take,  and  which  produces  a  fluid  move- 
ment with  the  least  amount  of  griping  and  distress 
to  the  patient.  Castor  oil,  though  most  children  do 
not  object  to  taking  it,  especially  if  sweetened  with 
syrup  or  honey,  is  nevertheless  a  potion  to  which 
few  adults  take  kindly.    To  an  adult,  it  might  how- 


Period  of 
Enforced 
Constipation 
in  Rectal 
Cases 


Drugs  for 

Postoperative 

Catharsis 


Formulae 


122     Guiding  Principles  in  Surgical  Practice 

ever  be  given  in  the  historic  form,  the  castor-oil 
sandwich. 


Rp.    .     . 

Sirupi  Rubi  Idaei 

fl.  3ij 

Glycerini 

fl.3j 

Olei  ricini 

fl.  Svij 

Spiritus  friimenti 

or  Spiritus  Vini  Gallici 

fl.Sij 

D.  Pour  carefully  into  a  graduated  medicine 
glass  in  the  order  given.  The  fluids  will  produce 
four  distinct  layers.  But  at  best,  it  is  a  bulky  dose, 
and  its  extemporaneous  preparation  is  too  compli- 
cated. 

An  attempt  of  mine,  to  avoid  these  objections, 
resulted  in  the  use,  for  a  time,  of  the  following 
prescription : 

Rp. 

Olei  tiglii  c.p.  mxvj. 

Olei  ricini 

Alcoholis  absoluti  aa  fl.  3ss 

Olei  foeniculi 

Olei  myristicae  aa  mxxx 

D.  S.  Average  dose,  fifteen  drops  in  a  little 
brandy.     Maximum  dose,  thirty  drops. 

In  this  combination,  the  potency  of  the  oleum 
tiglii  is  not  lost,  but  its  griping  effect  is  reduced  to 
a  minimum.  The  cathartic  is  very  prompt  and 
effectual  in  its  action.  The  drastic  effects  of  croton- 
oil  administered  in  the  undiluted  state,  such  as  blood 
in  the  dejecta,  I  have  never  observed,  even  with 
doses  of  half  a  fluid  drachm.     An  objection  to  the 


Guiding  Principles  in  Surgical  Practice     123 

general  use  of  such  a  cathartic,  however,  is  the  fact 
that  it  has  to  be  given  in  an  alcoholic  medium. 
Taken  in  milk,  it  seems,  that  at  times,  its  cathartic 
action  is  impaired. 

In  the  long  run,  it  is  calomel  still,  that  is  perhaps 
the  most  serviceable,  for  the  postoperative,  just  as 
in  the  preoperative  routine.  It  is  not  the  simple  stim- 
ulation of  an  after-dinner  pill,  but  prompt  and  reli- 
able evacuation  of  the  bowel  which  is  here  most  of- 
ten demanded.  The  calomel  should  be  administered 
in  a  single  dose  of  three  grains  to  the  adult,  excep- 
tionally two  grains.  It  is  a  mistake  to  give  it  in 
divided  doses  for  this  purpose.  Given  in  divided 
doses,  calomel  is  more  prone  to  produce  emesis 
when  the  stomach  is  irritable;  more  of  the  mercury- 
is  absorbed,  and  salivation  results  more  easily. 

In  the  rectal  case,  after  the  first  evacuation  of  the 
bowel,  the  chief  difficulty  is  passed.  The  nurse 
sees  to  it  that  the  patient's  diet  now  becomes 
cathartic  in  character  in  order  to  stimulate  the 
bowel  naturally,  and  in  order  to  preclude  consti- 
pated movements.  After  the  ordinary  laparotomy, 
or  for  that  matter,  after  perineal  operations  as  well, 
in  which  the  rectum  is  not  involved,  an  evacuative 
enema  of  plain  water  or  of  1  per  cent,  soap  suds 
is  ordered  after  the  third  day.  There  is  no  serious 
objection  to  giving  such  an  enema  earlier,  if  the 
indication  should  arise.  Not  uncommonly,  on  the 
day  following  operation,  a  low  peppermint  enema, 
for  instance,  is  administered  to  facilitate  the  ex- 
pulsion of  gas  which  distends  the  bowel  unduly. 

The  evacuative  enema  besides  freeing  the  large 
bowel  of  its  stagnating  contents,  aids  in  inciting 
more  active  peristalsis  in  higher  portions  of  the  gut, 


Enemata 


124    Guiding  Principles  in  Surgical  Practice 


Mild  Catharsis 


Normal  Full 
Diet 


and  thus  promotes  the  expulsion  of  gas  which  makes 
the  patient  uncomfortable. 

After  the  ordinary  laparotomy,  cathartics  by 
mouth,  when  given — generally  on  the  fifth  day — 
can  be  milder  and  more  varied  than  in  rectal  cases 
where  the  bowel  has  been  kept  inactive.  The  patient 
here  may  even  indicate  the  cathartic  which  she 
thinks  agrees  with  her  the  best,  and  which  she  has 
been  in  the  habit  of  using.  A  little  magnesium 
citrate,  or  the  aromatic  fluid  extract  of  cascara 
sagrada,  or,  a  simple  extract  of  cascara  sagrada 
pill  which  contains  no  harmful  ingredients,  is  not 
objectionable. 

The  transition  to  a  rational  full  diet  ought  to  be 
made  when  the  short  period  of  gas-pain  is  passed, 
the  habitual  bowel  activity  restored,  the  tempera- 
ture is  approaching  the  normal,  and  there  need  no 
longer  be  any  serious  scruple  about  readily  upset- 
ting the  patient's  digestion  by  granting  her  more 
latitude  in  her  meals.  Its  greater  variety  adds  a 
healthy  natural  stimulus  to  the  patient's  appetite 
and  digestion.  While  it  does  not  overtax  the 
patient's  digestive  powers,  it  demands  the  exercise 
of  the  normal  digestive  function.  Tlie  normal  full 
diet  which  is  least  inimical  to  the  digestive  and 
eliminative  organs  of  the  human  adult,  is  not  one, 
it  seems  to  me,  consisting  largely  of  meats,  nor  is 
it  a  strictly  vegetarian  diet,  as  others  would  have  it. 
I  have  myself,  for  the  sake  of  experiment,  lived  as 
a  fairly  strict  vegetarian  for  a  period  of  five  years 
(1895-1900),  and  although  the  term  is  too  short  to 
allow  me  to  draw 'many  conclusions  as  to  the  effect 
produced  in  the  human  system  by  excluding  animal 
food,  I  feel  warranted  in  saying  that  purely  vege- 
table food,  although  correctly  prepared  in  a  good 


Guiding  Principles  in  Surgical  Practice     125 


kitchen,  calls  for  a  digestive  energy  which  most  of 
us  do  not  naturally  possess,  and  which  is  not  readily 
developed  even  after  a  number  of  years  of  vege- 
tarianism. Also  animals  like  the  dog  can  be  fed, 
and  can  exist  on  vegetable  food,  but  it  seems  here 
too,  the  digestive  organs  are  not  quite  equal  to  their 
task.  A  healthy  English  greyhound  pup  was  re- 
stricted to  a  vegetable  diet,  from  which  all  meat 
was  excluded,  for  a  period  of  three  years;  the 
animal  relished  his  food,  grew  and  appeared  at  first 
to  develop  normally,  but  later  signs  of  subnormal 
nutrition  began  to  become  evident,  his  hair  grew 
dry  and  glossless,  the  musculature  somewhat  thin, 
though  of  good  quality,  panniculus  adiposus  scanty 
so  that  the  outline  of  the  ribs  was  pronounced.  Un- 
fortunately, I  cannot  record  the  corrective  influence 
of  a  change  in  the  animal's  food.  Some  hardened 
wretch,  soon  thereafter,  poisoned  with  strychnia, 
my  mute  companion  in  this  little  study  in  vege- 
tarianism. 

The  normal  full  diet  for  a  postoperative  case, 
should  not  be  an  extreme  diet ;  it  should  be  a  mixed 
diet  in  which  flesh  food  is  allowed  moderately,  once 
a  day,  or,  in  smaller  quantities  twice  a  day,  certainly 
not  oftener.  The  proper  cooking  of  vegetables  is 
a  lost  art,  and  as  a  consequence  perhaps,  the  aver- 
age individual  eats  too  much  meat.  The  constipated 
bowel  with  fluids  stagnating  in  the  caecum  and 
appendix,  and  the  torpid  liver  would,  no  doubt,  be 
helped  by  the  cathartic  influence  of  more  vegetable 
food. 

While  aiming  to  put  the  patient  on  the  normal 
full  diet  as  soon  as  this  is  feasible,  in  most  cases 
from  the  fourth  to  the  seventh  day  after  opera- 
tion, a  few  cannot  be  subjected  to  such  a  rapid 


Vegetarianism 


Excess   of 
Flesh  Food 


126    Guiding  Principles  in  Surgical  Practice 


Changes  of 

Position  after 

Operation 


transition,  and  may  have  to  remain  on  a  carefully 
supervised,  selected  convalescent  diet  throughout 
the  entire  period  of  their  recovery.  Occasionally 
one  meets  with  such  a  patient,  who  begins  to  eat 
and  digest  properly  the  moment  she  is  up  out  of  bed. 

With  few  exceptions,  the  laparotomy  case  may  be 
placed  on  her  side  on  the  first  or  second  day  after 
operation.  Of  course,  if  she  is  a  very  adipose 
woman  with  an  abdomen  which  overflows  the  iliac 
crests,  it  is  wiser  to  keep  her  on  her  back  during 
the  entire  postoperative  period.  After  a  few  days 
such  patients  begin  to  become  used  to  this  position, 
and  do  not  feel  the  restriction  as  they  did  at  first. 
After  operations  on  the  female  perineum,  the  lateral 
posture  enables  the  wound  to  be  kept  dry  by  allow- 
ing the  accumulating  discharge  to  gravitate  away 
from  the  suture  line — this  point,  I  think,  is  vital 
in  obtaining  successful  union  in  complete  tears  of 
the  female  perineum.  In  inguinal  or  femoral 
hernioplasties,  a  lesson  is  to  be  learned  from  child- 
ren who  are  wont  to  lie  on  the  operated  side — 
evidently  the  position  of  comfort.  Under  ordinary 
conditions  there  need  be  no  hesitancy  in  permitting 
this  in  the  case  of  adults,  except  where  an  operation 
for  hernia  has  been  done  on  both  sides.  It  should 
be  our  endeavor  to  see  how  admirably  nature  often 
points  out  the  way  to  us,  if  we  will  but  study  her 
with  a  little  insight.  A  sad  spectacle  is  he  who 
looks  for  therapeutic  indications  only  in  books,  and 
neglects  to  discover  them  in  his  patients. 

The  patient's  second  week — the  week  of  waiting 
— should,  to  the 'fullest  extent,  be  made  available 
for  her  mental  and  physical  rehabilitation.  During 
the  day  her  mind  is  kept  occupied,  to  prevent  undue 
introspection  and  brooding.    Wire  puzzles,  Japanese 


Guiding  Principles  in  Surgical  Practice     127 

puzzles  with  complicated  dove-tailing,  engage  the  xhe  Second 
hands  and  brain,  or  brass-punching,  or  modeling  in  Week 
artist's  clay,  or  folding  gauze  for  the  operating- 
room,  are  all  better  than  fine  needle-work  or  much 
reading.  A  male  patient  may  derive  considerable 
pleasure  from  a  cigar,  it  is  not  encouraged  but 
allowed;  while  another  with  a  constructive  bent, 
begins  to  while  away  his  time  by  whittling  some 
chess  figures,  or  a  wooden  chain.  It  is  sometimes 
necessary  to  discriminate  between  visitors.  Mem- 
bers of  the  family  or  friends  with  a  cheerful  dis- 
position are  desirable,  and  may  help  to  modify  the 
patient's  mood. 

After  gynecological  operations  where  the  median 
vertical,  the  mesial  rectus,  or  the  semilunar  hypo- 
gastric incision  is  used,  the  lower  border  of  the 
dressing  is  secured  by  means  of  a  strip  of  zinc  oxide  Methods  of 
adhesive  two  inches  wide,  before  the  patient  is  taken  Retaining  the 
from  the  operating-room.  The  strip  reaches  from  Dressing 
the  outside  of  one  hip,  to  the  outside  of  the  opposite 
one.  It  overlaps  the  dressing,  about  three-quarters 
of  an  inch. below,  where  it  is  made  to  adhere  firmly 
to  the  symphysis,  immediately  above  the  vulvar  in- 
cisure. Sponging  the  area  with  a  little  ether  or 
liquor  expurgans,  aids  materially  in  obtaining  good 
adhesion  of  the  plaster.  An  oblique  incision  of 
about  one  inch,  in  the  direction  of  each  inguinal 
fold,  makes  possible  better  adaptation,  and  prevents 
the  plaster  from  being  pulled  or  lifted  away  from 
the  symphysis  so  readily  when  the  thighs  are  flexed. 
Laparotomy  straps  consisting  of  strips  of  adhesive 
plaster  one  inch  in  width  with  tapes  attached,  two 
or  three  on  each  side  of  the  abdomen,  are  tied  over 
the  dressing  to  keep  it  in  place.  In  their  stead,  a 
single  wide  piece  of  adhesive  on  each  side,  lined  with 


128    Guiding  Principles  in  Surgical  Practice 

rubber  tissue,  or  with  a  single  layer  of  gauze  where 
it  touches  the  dressing,  can  be  laced  in  front  in  the 
manner  of  a  corset.  Nevertheless,  in  either  case, 
it  is  well  not  to  discard  the  traditional  plain,  or 
many  tailed  binder  which  affords  additional  support 
and  protection  to  the  wound.  In  very  fat  subjects 
with  a  large  incision,  the  wound  is  not  supported 
sufficiently,  even  with  a  snugly  applied  binder,  and 
it  is  safer  to  encircle  the  abdomen  with  broad  (four 
inch)  strips  of  zinc  oxide  plaster  beginning  below 
and  allowing  each  tour,  to  be  overlapped  partly  by 
the  next,  while  the  ends  cross  each  other  in  front 
obliquely,  over  the  dressing.  I  have  had  occasion 
to  regret  my  neglect  to  observe  this  precaution,  in 
a  rather  adipose  patient  in  whom,  on  account  of  the 
magnitude  of  the  pelvic  tumor,  a  large  incision  was 
necessary.  During  a  violent  coughing  spell,  the 
entire  suture-line  was  burst  open,  allowing  the  in- 
testines, partly  covered  by  the  omentum,  to  escape 
into  the  grasp  of  the  dressing.  Although  the  suture 
had  been  carefully  done  by  layers,  the  catgut  had  cut 
through  the  friable  tissues,  each  knot  still  remaining 
securely  tied.  In  the  case  of  an  inguinal  or  femoral 
hernia,  the  best  support  is  given  by  a  firmly  applied 
spica.  The  bandage  should  be  not  less  than  four 
inches  wide  for  the  adult,  and  the  bony  prominences 
padded  with  non-absorbent  cotton.  In  most  cases 
it  is  indicated  to  reen force  the  bandage  with  a  single 
figure-of-eight  tour  of  adhesive  plaster. 

Unless  there  has  been  some  complication  in  the 

The  First  normal  wound-healing,  the  first  dressing  is  not  due 

Dressing  until  the  fifth,  sixth  or  seventh  day  after  operation. 

In  laparotomies  dressed  in  the  manner  described, 

it  is  merely  necessary,  after  undoing  the  tape  of  the 

straps  or  adhesive  corset,  to  reflect  the  dressing 


Guiding  Principles  in  Surgical  Practice     129 

downward  over  the  pubes,  when  the  suture  line 
comes  to  view.  If  there  is  no  redness  or  moisture 
about  the  stitches,  no  tender  infiltration  to  the  touch, 
the  wound  has  healed  by  primary  intention.  Indeed, 
that  is  what  is  to  be  expected  if  the  postoperative 
temperature  chart  shows  no  deviation  from  the  nor- 
mal aseptic  reaction.  If  absorbable  material  has 
been  used  for  suturing  the  skin,  the  patient  learns 
with  satisfaction,  that  contrary  to  her  expectation, 
no  sutures  have  to  be  removed.  Michel's  skin 
clamps  call  for  an  early  dressing,  generally  on  the 
fifth  day.  In  case  adhesive  strips  have  been  used 
for  skin-closure,  early  dressing  is  not  vital.  Silk- 
worm gut  sutures  at  the  angle  of  a  secreting  or  dis- 
charging wound,  or  in  flaps  which  are  under  ten- 
sion, as  after  radical  operations  for  cancer  of  the 
breast,  or  in  the  perineum,  had  better  be  left  until 
the  twelfth  day.  Silver  leaf  cut  into  small  squares 
and  sterilized  in  packets  of  a  dozen  or  more,  between 
two  squares  of  thin  wood  (J.  S.  Lewis),  has  oc- 
casionally been  used  to  cover  the  suture-line  im- 
mediately after  operation,  in  order  to  prevent  the 
gauze  dressing  from  adhering  to  it.  At  the  first 
dressing  the  silver  leaf  is  found  more  or  less 
minutely  pulverized,  and  where  there  is  oozing  from 
the  incision,  it  tends  to  create  an  undesirable  crust. 

The  removal  of  drains  of  rubber  tissue  or  tubing  Drains 
from  aseptic  wounds  where  there  is  much  oozing, 
is  occasionally  necessary.  Thus  after  the  radical 
operation  for  cancer  of  the  breast,  drainage  of  the 
axilla  for  24-48  hours  is  required  to  remove  the 
accumulating  lymph,  and  this  necessitates  an  early 
dressing.  At  one  time  drainage  was  almost  a 
routine  after  the  ordinary  hernioplasty.  In  this  case 
the  pressure  exerted  upon  the  wound  dressing  when 


130    Guiding  Principles  in  Surgical  Practice 


Temporary 

Support    after 

Operation 


the  bandage  is  properly  applied,  ought  to  be  suffi- 
cient to  prevent  the  accumulation  of  much  lymph  or 
blood.  Much  depends  upon  the  proper  application 
of  the  spica.  In  obese  individuals  difficulty  in  this 
regard  is  obviated,  by  obliterating  the  gaping  spaces 
in  the  subcutaneous  fat  at  the  time  of  the  operation, 
by  means  of  a  thin  absorbable  suture.  It  is  surely 
better,  to  attend  to  such  details  with  proper  pre- 
cision while  the  patient  is  under  the  anesthetic,  than 
to  be  encumbered  later  at  the  dressing  by  complica- 
tions which  might  have  been  avoided,  and  then 
attempt  to  make  good  a  neglect. 

Where  reasonable  care  and  circumspection  have 
been  exercised  at  the  operation,  the  postoperative 
treatment  usually  becomes  a  simple  matter  as  far 
as  the  surgeon  is  concerned.  The  routine  first  dress- 
ing on  the  fifth,  sixth  or  seventh  day  after  operation 
includes  the  removal  of  skin  sutures  or  clamps  or, 
when  an  absorbable  skin  suture  was  employed,  con- 
sists in  little  more  than  an  inspection  of  the  wound, 
and  the  substitution  of  a  new  piece  of  sterile  gauze 
for  the  one  which  has  been  in  contact  with  the 
incision. 

In  gynecological  cases  the  protective  gauze  pad 
which  was  reflected  for  the  dressing,  is  returned  to 
its  place,  and  the  laparotomy  straps  or  corset  flaps 
are  fastened  over  it,  as  before.  Only  at  the  second, 
that  is  the  last  dressing,  the  entire  adhesive  support 
is  removed,  and  the  skin  freed  from  the  adherent 
zinc  oxide  by  means  of  benzine,  ether,  or  liquor 
expurgans.  If  there  happens  to  be  a  point  in  the 
wound  where  the  apposition  was  not  good  and  heal- 
ing was  delayed,  a  tiny  bit  of  sterile  gauze  and  a 
small  strip  of  adhesive,  are  all  the  dressing  requires. 
The  area  where  the  plaster  has  been,  is  thoroughly 


Guiding  Principles  in  Surgical  Practice     131 

powdered  by  the  nurse.  A  supporting  belt  need 
rarely  be  ordered.  The  so-called  ''straight  front" 
corsets  which  are  now  in  vogue,  are  constructed  on 
sounder  principles  than  the  old-fashioned  type ;  the 
abdomen  is  lifted  from  below  upward,  and  adequate 
support  is  given  to  the  young  and  distensible  scar. 
A  corset  of  neat  pattern  has  been  constructed  which 
consists  of  two  pieces,  one  shifting  over  the  other, 
and  which  allows  more  freedom  in  bending  the  body 
forward.  It  is  well  adapted  to  the  needs  of  cor- 
pulent patients  with  a  pendulous  abdomen,  who  are 
otherwise  difficult  to  fit  properly.  The  nurse  in- 
structs the  patient  to  apply  the  corset  in  the  re- 
cumbent posture,  and  to  lace  it  always  from  below 
upward.  Cases  of  inguinal  or  femoral  hernio- 
plasty  leave  the  hospital  wearing  as  a  temporary 
support  of  the  recently  healed  wound,  a  tightly 
wound  spica.  This  is  reapplied  once  more  as  soon 
as  it  loosens,  which  is  usually  in  the  course  of  a 
week. 

The  question,  "When  shall  the  patient  be  allowed 
out  of  bed  after  an  aseptic  laparotomy?"  has  evoked 
diverging  opinions.  Some  surgeons  lay  little  stress 
on  the  stretching  of  the  scar,  and  the  possibility  of 
a  postoperative  hernia.  But  it  seems  unfair  to  the 
patient  to  disregard  these  factors,  and  better  to 
retain  the  average  aseptic  laparotomy  in  the  recum- 
bent position  for  not  less  than  tzvelve  days.  In  the  the^PatVent 
case  of  a  fat  individual  with  poor  healing  power,  an  sit  Up  in  Bed? 
additional  week  is  not  superfluous.  To  keep  a 
patient  in  the  horizontal  plane  of  her  bed,  does  not 
necessarily  imply  that  she  should  be  immobile.  The 
use  of  the  extremities  and  changes  of  posture,  pro- 
mote the  venous  return  and  are  helpful,  rather  than 
detrimental,  so  long  as  no  strain  is  put  upon  the 


When  may 


132    Guiding  Principles  in  Surgical  Practice 


Report  to 

the    Family 

Physician 


incision.  Cavil  none  will,  that  the  patient  can  be 
gotten  up  almost  any  day  after  operation,  but  the 
salient  point  at  issue  is  not  what  can  be  done,  but 
what  is  most  adequate  if  the  patient's  future  wel- 
fare is  considered.  Indeed,  for  that  matter,  it  might 
be  safer  to  allow  a  patient  to  sit  up  on  the  third 
day  after  an  abdominal  section,  than  on  the  sixth 
or  seventh,  when  the  stitches  begin  to  be  dissolved. 

By  far  the  greater  number  of  laparotomies  are 
uncomplicated  in  their  recovery,  and  can  be  dis- 
charged from  the  hospital  on  the  fourteenth  day 
of  their  stay.  On  the  morning  of  the  day  before 
dismissal,  the  patient  for  the  first  time  assumes 
the  vertical  position,  she  is  permitted  to  sit  up  in 
bed.  Some  patients,  particularly  anemic  ones,  are 
inclined  to  become  dizzy  during  this  first  attempt, 
and  a  hot,  exhilarating  drink  may  be  given  as  a 
prophylactic  measure.  In  the  afternoon,  the  patient 
is  allowed  to  sit  in  a  chair.  On  the  morning  of  the 
last  day,  a  final  revision  of  her  condition  is  made. 
She  will,  by  this  time,  have  partly  reaccustomed  her- 
self to  be  up  and  about,  and  is  prepared  for  the 
event  of  her  departure. 

As  soon  as  the  patient  is  dismissed  from  the 
surgeon's  care,  important  data  and  details  concern- 
ing her  condition  should  be  transmitted  to  the 
family  physician  or  specialist  into  whose  hands  she 
reverts.  It  is  an  attention  due  the  patient,  as  well  as 
the  physician  who  has  to  take  further  charge  of 
her,  and  now  becomes  responsible.  Perhaps  some 
of  the  problems  concerning  the  proper  ethics  to  be 
observed  between*  physician  and  surgeon  regarding 
the  transfer  of  a  case,  may  become  very  much 
simplified,  if  both  truly  agree  that  the  patient's 
best  interest  should  determine  their  course. 


Fever 


CHAPTER  XII 

The  Interpretation  of  Post-Operative  Fever  in 

Aseptic  Cases 

It  is  a  matter  of  common  knowledge,  that  every 
operation  on  an  aseptic  case  is  physiologically  fol- 
lowed by  a  slight  rise  in  temperature,  which  is  not 
due  to  infection.  The  rise  in  temperature  is  so 
definite  and  uniform  in  its  behavior,  that  the  con- 
ception of  a  typical  aseptic  wave  seems  well  founded. 
Naturally,  the  normal  reaction  is  most  evident  in  Aseptic 
cases  with  a  strictly  uncomplicated  recovery.  In 
practice,  such  cases  are  the  exception,  and  there  is 
therefore  usually  imperative,  a  more  critical  analy- 
sis of  the  post-operative  fever-curve,  in  order  to 
distinguish  the  general  trend  of  the  fundamental 
reaction,  from  that  which  is  incidental,  and  due  to 
some  complicating  factor. 

But  what  are  the  essential  characteristics  of  the 
typical  aseptic  reaction?  The  problem  may  be 
approached  directly  by  eliminating  at  once,  from 
this  study,  all  pus  cases,  in  fact,  all  cases  which  have 
not  a  normal  temperature  before  operation.  As  a 
matter  of  course,  a  correct  picture  of  the  aseptic 
reaction  can  only  be  expected  in  a  case  which  is 
primarily  aseptic,  and  in  which  even  the  minor 
details  of  asepsis  during  operation  have  been 
watched  with  particular  scrutiny. 

As  a  result  of  such  an  attempt  to  define  the 
aseptic  reaction,  the  following  deductions  may  be 
recorded : 

(133) 


Data 


134    Guiding  Principles  in  Surgical  Practice 

(1)  The  mean  daily  rectal  temperature  is  nor- 
mally about  99.1°  F.  The  daily  fluctuation  is  ap- 
proximately 0.6°  F.  That  is,  the  highest  normal 
reached  during  the  day  is  99.4°  F. ;  the  lowest  is 
98.8°  F.  (Illustrated  in  Table  I). 

(2)  The  mean  daily  oral  temperature  is  nor- 
mally about  98.4°  F.,  that  is,  about  0.7°  F.,  or  a  little 
more  than  half  a  degree  lower  than  the  mean  rectal 
temperature.  The  oral  temperature  varies  more 
widely  than  the  rectal;  approximately  0.8°  F.,  the 
minimum  being  98°  F.,  and  the  maximum  about 
98.8°  F.  under  normal  conditions. 

(3)  The  difference  between  rectal  and  oral 
temperature  does  not  remain  constant  in  the  same 
patient,  as  the  temperature  rises.  It  is  not  accurate 
to  compute  from  the  fever-curve,  obtained  by  re- 
cording the  mouth  temperature,  the  corresponding 
rectal,  or  vice  versa,  by  adding  or  subtracting  a 
constant  factor.     (Illustrated  in  Table  II.) 

(4)  The  temperature  obtained  in  the  proximity 
of  the  surgical  lesion,  represents  more  nearly  the 
true  reaction,  than  that  obtained  at  some  remote 
part  of  the  body.  When  the  pelvic  or  abdominal 
organs  are  concerned,  as  in  gynecological  operations, 
and  the  greater  number  of  operations  in  general 
surgery,  the  excursions  of  temperature  are  more 
correctly  indicated  by  the  rectal,  than  by  the  oral 
reading.     (Illustrated  in  Table  III.) 

(5)  There  is  normally  a  slight  post-operative 
temperature  rise  which  is  not  traceable  to  infection 
— ^the  aseptic  fever. 


Guiding  Principles  in  Surgical  Practice     135 

(6)  The  maximum  rise  or  acme  in  the  normal 
post-operative  curve  of  aseptic  cases,  may  occur  as 
early  as  4  hours,  and  as  late  as  33  hours  after 
operation,  without  being  pathognomonic.  The  com- 
puted average  time  in  one  series  of  cases  was  18 
hours.  (Table  IV.)  As  a  rule,  the  maximum  rise 
is  reached  within  24  or  36  hours — a  day,  or  a  day 
and  a  half  after  operation. 

(7)  The  average  maximum  rise  is  about  100.6° 
F.,  and  should  not  exceed  101°  F.,  rectal  tempera- 
ture.    (Illustrated  in  Table  IV.) 

(8)  The  time  of  day  during  which  the  operation 
is  done  has  a  slight,  though  neither  a  uniform  nor 

vital  bearing  on  the  post-operative  reading.  Qg^^.^ 

(9)  The  maximum  rise  or  acme  may  be  more 
or  less  acute,  followed  at  once  by  a  remission,  and 
this  is  the  rule;  or,  very  rarely,  the  wave  may  have 
a  plateau-like  summit;  exceptionally  in  such  event, 
the  same  temperature  may  persist  without  any  ap- 
preciable remission,  as  long  as   nine  hours. 

(10)  There  is  normally  a  well  defined  second 
rise,  a  post-maximal  rise,  on  the  day  following  the 
maximum  rise,  but  it  should  never  exceed  the  former 
in  amplitude  unless  there  is  some  complicating 
factor. 

(11)  Exceptionally  a  small  abortive  wave — a 
pre-maximal  wave — may  immediately  precede  the 
maximum  rise.  This  should  not  lead  to  confusion 
in  interpreting  the  temperature  chart. 

(12)  In  general,  in  the  wholly  uncomplicated 
case,  the  temperature  waves  on  successive  days  may 


136    Guiding  Principles  in  Surgical  Practice 

be  expected  to  show  a  gradual  subsidence  in  ampli- 
tude; and  reach  the  normal,  in  the  course  of  five 
days,  or  at  the  end  of  a  week. 

(13)  The  daily  average  temperature,  or  mean 
temperature,  tozvards  the  end  of  the  second  week 
after  operation,  is  apt  to  be  a  little  lower,  than  that 
obtained  for  the  same  patient  before  operation. 
Thus,  it  is,  at  the  end  of  the  second  week,  about 
98.7°  F.  by  rectum  (Table  V),  and  about  98.2°  F. 
by  mouth  (Table  II.) 

(14)  In  taking  oral  temperature,  the  sources  of 
error  are  greater,  and  the  individual  variations  in 
temperature  less  pronounced  so  that  they  may  be 
overlooked  altogether.  Oral  readings  do  not  repre- 
sent the  actual  magnitude  of  the  reaction,  when  a 
celiotomy  is  in  question.  They  do  not  offer  a  very 
satisfactory  basis  for  study. 

Utilizing  these  findings  the  characteristic  reaction 
The  Schematic  which  follows  operations  on  aseptic  cases,  the 
Curve  aseptic  fever-wave  may  be  represented  graphically 
and  schematically  (Chart  I). 

As  soon  as  the  theory  that  a  typical  curve  repre- 
sents the  aseptic  reaction  following  clean  operations, 
can  be  considered  established,  it  becomes  a  simple 
matter  of  bedside  study  to  discover  the  meaning  of 
anomalous  fluctuations.  Indeed,  every  departure 
from  the  typical  aseptic  wave,  requires  its  interpre- 
tation. On  the  one  hand,  must  be  considered  devia- 
tions representing*  minor  complications  which  are 
of  no  grave  import,  as  for  instance,  stagnation  in 
the  bowel,  or  onset  of  menstruation  in  cases  with 
an  old  pelvic  trouble,  a  bronchial  catarrh,  and  even 


Guiding  Principles  in  Surgical  Practice     137 

a  superficial  wound-infection;  on  the  other  hand, 
those  which  are  the  expression  of  serious  complica- 
tions, such  as  a  deep  wound-infection,  peritonitis 
or  sepsis.  This  conception  at  once  enhances  the 
clinical  significance  of  the  temperature  record,  and 
suggests  a  way  to  the  more  intelligent  reading  of  it, 
on  the  part  of  the  surgeon. 

To  begin  with,  it  seems  best  to  select,  for  the  Actual  Curve 
sake  of  illustration,  an  actual  case  (Chart  II),  which  °*  Aseptic 
demonstrates  the  normal  course  of  aseptic  fever, 
and  embodies  all  the  points  already  emphasized  in 
the  schematic  representation  of  the  aseptic  wave. 
Here  aberrations  in  the  temperature,  which  are  due 
to  infection,  bowel  stasis,  or  other  minor  complica- 
tions are  absent. 

By  all  odds,  the  most  frequent  source  of  slight, 
or  even  marked  disturbance  in  the  normal  reaction 
after  operation,  is  stagnation  in  the  bowel.  Because 
the  period  of  constipation  is  at  first  too  brief,  the 
maximum  rise  itself  need  not  be  influenced  at  all. 
But  indicative,  is  a  slight  rise  on  the  fourth  or  fifth 
day,  which  can  be  promptly  corrected  by  the  enema 
or  calomel. 

This  rise  may  sometimes,  however,  appear  a  little 
earlier,  and  become  alarming  on  account  of  its 
height,  especially  where  the  stasis  is  pronounced, 
as  when  the  patient's  bowel  has  not  been  properly 
evacuated  before  operation.  A  chart  which  illus-  Effect  of 
trates  this  point,  is  that  of  a  patient,  in  whom,  Bowel  Stasis 
contrary  to  the  rule,  home  preparation  of  the*  bowel 
was  relied  upon  (Private  Record  No.  2301,  N. 
P.,  1909).  The  temperature  rose  to  104.4°  F. 
per  rectum  on  the  third  and  fifth  days;  the  pulse 


138    Guiding  Principles  in  Surgical  Practice 


Influence 

of 

Menstruation 


rate,  which  was  normally  76  to  78,  however,  re- 
mained comparatively  slow,  varying  only  between 
100  and  106  per  minute  during  this  time,  and  the 
respiration  from  22  to  28.  After  a  very  effectual 
washing  of  the  bowel  the  temperature  dropped  to 
the  normal.  There  was  no  tenderness,  infiltration 
or  hematoma,  no  redness  or  secretion  about  the 
incision,  which  was  found  healed  by  primary  inten- 
tion on  the  sixth  day.  It  seemed  clear  that  the 
bowel  alone,  was  responsible  for  this  anomalous 
reaction.    (Chart  III.) 

In  some  instances,  in  female  patients,  a  slight  rise 
of  temperature  occurs,  accompanied  perhaps  by  a 
few  nervous  symptoms,  a  sensation  of  weight  and 
discomfort  in  the  pelvis,  and  feeble  recurrent  pain 
in  the  back  occasionally  radiating  into  the  thighs. 
The  disturbance  cannot  be  traced  to  the  condition 
of  the  bowel,  and  may  remain  obscure,  until  a  few 
days  later,  when  the  nurse  reports  that  the  patient 
is  menstruating.  The  rise  probably  appeared  co- 
incident with  the  pelvic  vascular  hypertension  which 
may  precede  the  actual  appearance  of  the  menstrual 
blood  by  one  or  two  days.  But  it  does  not  seem 
entirely  correct  to  ascribe  it  to  the  physiological 
menstruation.  Under  strictly  normal  conditions  of 
the  pelvic  organs,  there  should  be  no  secondary  rise 
— post-maximal  rise — ascribable  to  menstrual  py- 
rexia, which  exceeds  the  maximum  rise  in  ampli- 
tude. A  number  of  observations  speak  for  the 
assumption  that  when  such  a  rise  occurs,  it  points 
to  an  old  iflammatory,  toxin-producing  focus  some- 
where in  the  pelvis,  which  is  not  completely  healed, 
and  the  temperature  can  be  explained  by  the  in- 


Guiding  Principles  in  Surgical  Practice     139 


creased  absorption  incident  upon  the  menstrual 
cycle.  It  may  be  a  chronic  salpingitis  for  example, 
which  presents  no  appreciable  temperature  rise  dur- 
ing the  intermenstrual  period,  but  shows  a  distinct 
"absorption  rise"  with  every  oncoming  menstrua- 
tion.    (Chart  IV.) 

The  assumption,  that  in  the  absence  of  pelvic 
inflammation,  menstruation  itself  does  not  materially 
modify  the  typical  temperature,  is  strengthened  by 
the  fact  that  operations  performed  during  the  period 
of  menstruation  show  essentially  the  same  maximum 
rise,  as  those  done  in  the  intermenstrual  time.  Thus, 
for  example,  after  enucleating  a  number  of  uterine 
fibroids,  and  removing  the  appendix  in  a  young 
woman  on  the  fourth  day  of  her  menstruation,  she 
continued  to  menstruate  for  three  days  after  opera- 
tion. On  the  one  hand,  the  inaugurated  flow  was 
not  interrupted  by  the  surgical  measure;  on  the 
other,  as  reference  to  the  patient's  previous  history 
shows,  its  duration  was  not  changed.  The  operation 
occurring  on  the  fourth  day  was  exactly  midmen- 
strual  in  time.  Notwithstanding  this  fact,  the  post- 
operative reaction  was  practically  the  same  as  that 
obtained  in  other  cases  operated  between  periods. 
The  rectal  temperature  fluctuated  between  98.4°  F. 
— 99.4°  F.  in  the  twenty-four  hours  preceding 
operation.  That  is,  the  mean  daily  temperature  was 
98.9°  F.  The  maximum  rise  was  reached  in  twenty- 
nine  hours  after  operation.  It  was  101°  F.  The 
second  rise — post-maximal  rise — on  the  third  day, 
reached  100.2°  F.,  and  on  the  fourth  day  the  acme 
was  99.8°  F.     (P.  R.  No.  3429,  C.  V.) 

Before  concluding  that  a  fluctuation  in  tempera- 
ture is  anomalous,  it  is  not  to  be  forgotten  that 


Operation 
During  the 
Menstrual 
Period 


140    Guiding  Principles  in  Surgical  Practice 


Influence  of  a 

Mild  Skin 

Infection 


More 

Marked  Skin 

Infections 


secondary  rises  occur  on  the  days  following  opera- 
tion, but  that  a  complicating  factor  is  to  be  thought 
of  only  when  these  exceed  the  primary  one. 

There  is  another  point  of  interest  in  the  tempera- 
ture curve  of  this  patient.  Although  the  menstrua- 
tion had  ceased,  and  there  was  no  bowel  stasis, 
there  was  a  rise  to  100.4°  F.  on  the  fifth  day,  another 
to  100.6"  F.  on  the  sixth,  100.4°  F.  on  the  seventh, 
then  99.8°  F.,  followed  by  a  subsidence  to  the  nor- 
mal. As  soon  became  evident,  this  slight  pyrexia 
had  its  origin  in  the  wound.  It  represented  one  of 
the  mild  skin  infections,  in  which  a  tiny  focus 
promptly  drains  itself  on  the  surface.  Similar  per- 
turbations occur  not  infrequently  in  vaginal  opera- 
tions, or  other  operations  involving  the  mucous 
membrane,  where  it  is  difficult  to  obtain  satisfactory 
surface  sterility. 

Such  mild  wound  infections  as  these  cause  no 
marked  constitutional  distrubance  and  very  likely 
often  escape  notice,  but  there  are  others  which  must 
still  be  classed  as  belonging  to  the  group  of  minor 
complications,  although  they  present  a  more  elabor- 
ate clinical  picture.  In  these  severer  cases,  the  ex- 
istence of  the  local  infection  may  be  indicated  by 
some  aberration  in  the  temperature  very  soon  after 
operation ;  nevertheless  a  pronounced  rise — 102°  F. 
or  103°  F. — accompanied  by  notable  systemic  dis- 
turbances and  symptoms  referable  to  the  wound,  is 
never  likely  to  occur  until  the  sixth  or  seventh  day. 
In  other  words,  allowance  must  be  made  for  a 
definite  period  of  incubation.  The  pulse  rate  and 
respiration,  just  as  in  many  other  comparatively 
innocent  complications,  do  not  keep  pace  with  the 
excursions  of  the  fever.     To  amplify  these  points 


Guiding  Principles  in  Surgical  Practice     141 


reference  might  be  made  to  the  post-operative  be- 
havior of  a  case,  in  which  beyond  all  reasonable 
doubt,  the  contamination  of  the  wound  had  its 
origin  in  the  follicular  and  glandular  skin  of  the 
pubic  region.     (Chart  VI.) 

In  this  chart,  for  clinical  reasons,  but  unhappily 
for  numerical  comparison  with  the  preceding  ones, 
the  mouth  temperature  only  is  recorded.    The  pre-  Case 
operative  temperature  showed  a  daily  fluctuation  Illustrating 

between  97.2°  F.  and  98.6°  F.  per  os.     The  pulse  t*"  f^*e*,°* 

^  Marked  Skin 

ranged  from  66  to  72,  and  the  average  frequency  of  infection 

respiration  was  20.    The  operation  was  done  at  ten 

o'clock  in  the  morning,  and  up  to  thirty-four  hours 

after  it,  the  record  of  temperature  was  as  follows : 


6  hours 

P- 

3.      100.2° 

F. 

oral 

10      " 

«  < 

100.4° 

14      " 

it  ( 

100.8° 

"  P.86R.20 

18      " 

It  < 

100.2° 

22      " 

«  « 

99.6° 

26      " 

«  it 

99.4° 

30      " 

a    « 

99.4° 

34      " 

«    (t 

101.2° 

"  P.  76  R.  20 

Here  the  primary  or  maximum  rise  is  at  midnight 
of  the  day  of  the  operation,  and  twenty  hours  later 
there  is  a  second  rise,  which  is  greater  than  the 
first,  and  is  to  be  considered  abnormal.  There  were 
at  the  time  no  subjective  symptoms  whatever  to 
lead  to  the  suspicion  of  a  future  complication  in 
wound-healing.  A  few  days  after  operation,  how- 
ever, the  profuse  sweating  of  the  patient  attracted 
attention,  notwithstanding  that  the  summer  was 
exceptionally  warm;  but  there  was  no  complaint 
of  pain  in  the  region  of  the  wound  until  the  fourth 


142    Guiding  Principles  in  Surgical  Practice 

day.  On  the  day  following  this,  there  were  ex- 
perienced indefinite  shifting  pains  in  the  neck,  knee, 
wrist  and  arm,  unaccompanied  by  any  swelling  of 
the  joints.  The  pains  became  more  pronounced  on 
the  sixth  day,  when  the  remittent  temperature 
reached  its  acme  with  103.2°  F.  per  os.  Neverthe- 
less the  pulse  remained  relatively  slow,  and  the 
heart  action  normal.  The  first  impression  of  these 
symptoms  was  quite  misleading.  Typhoid  fever  or 
malaria  could  readily  be  differentiated,  but  with 
much  less  certainty  an  atypical  articular  rheumatism, 
in  its  onset.  The  lower  border  of  the  spleen  was 
not  palpable,  but  the  organ  measured  three  inches 
in  the  axillary  vertical.  The  blood  examination 
showed 

CeM  Coum  White  cells  18.400 

Polymorphnuclear  neutrophiles  91.5% 
Small  lymphocytes  5.5% 

Large  lymphocytes  1.0% 

Eosinophiles  2.0% 

No  Plasmodia ;  Widal  reaction  negative. 

A  faint  redness  of  the  wound-line  at  first,  was 
succeeded  after  the  sixth  day  by  a  separation  of 
the  wound  near  its  middle,  to  the  extent  of  about 
half  an  inch,  with  the  discharge  of  a  small  quantity 
of  odorless  pus.  After  this  free  drainage  the  tem- 
perature gradually  subsided,  and  on  the  thirteenth 
day  the  little  granulating  gap  which  reached  to  the 
surface  of  the  external  oblique  aponeurosis,  was 
closed  by  apposing  the  wound-lips,  and  applying 
sterile  zinc  oxide  strips.  The  temperature  con- 
tinued to  remain  normal. 


Cold 


Guiding  Principles  in  Surgical  Practice     143 

In  analyzing  the  effect  of  the  various  minor  com- 
plications, intercurrent  ailments  of  slight  severity 
must  also  be  borne  in  mind.  Exceptionally  a  "ca-  ^^^^^^  °^  * 
tarrhal  fever,"  "la  grippe"  or  "influenza  nostras," 
as  the  condition  has  been  variously  called,  may  ex- 
plain an  anomaly  in  the  post-operative  reaction. 
Illustrative  of  this  is  the  temperature  of  a  patient, 
on  whom  an  abdominal  plastic  had  to  be  done  for 
a  post-operative  ventral  hernia,  a  sequel  of  the  old 
method  of  treating  cases  of  pyosalpinx  by  supra- 
pubic drainage.     (Chart  VII.) 

In  the  primary  rise,  which  persists  from  the  ninth 
to  the  eighteenth  hour  after  operation,  the  ther- 
mometer registers  100.6°  F.  per  rectum.  This  in 
itself  need  not  be  considered  abnormal.  But  the 
second  rise  on  the  third  day  was  100.8°  F.,  that  is, 
apparently  greater  than  the  primary  rise,  and  the 
aberration,  with  proper  reserve  because  of  the 
slightness  of  the  difference,  is  taken  to  indicate  some 
foreign  influence.  The  recurrence  of  a  rise  of 
100.8°  F.  on  the  fifth  day  is  however  clearly  patho- 
logical, and  the  slight  pain  in  the  chest,  cough  and 
mucous  expectoration  at  this  time,  explained  its 
source.  The  usual  causes  of  fluctuations  in  the 
typical  curve,  were  absent.  There  was  no  tender- 
ness over  the  wound-line;  no  bowel  stasis.  On  the 
seventh  day  the  temperature  reached  102°  F.  The 
daily  excursion  in  temperature  was  from  100.4"  F. 
to  102°  F.  per  rectum.  The  pulse  rate  varied  be- 
tween 80  and  108,  The  cough  continued.  Examina- 
tion of  the  chest  showed  the  typical  signs  of  a 
catarrhal  bronchitis.  The  variation  of  the  fever  on 
the  eighth  day  was  from  101°  F.  to  101.8°  F.,  and 
the  pulse  frequency  from  100  to  104.  The  sputum 
became  greenish  in  color,   and  was  moderate  in 


144    Guiding  Principles  in  Surgical  Practice 

quantity.  The  rales  diminished.  The  next  day  the 
temperature  dropped  from  its  maximum  of  100.2° 
F.  to  99°  F.  The  highest  wave  was  100°  F.  on  the 
tenth,  and  99.6°  F.  on  the  eleventh  day,  and  with 
the  subsidence  of  the  temperature,  the  cough  also 
disappeared.  There  can  be  little  question,  that  the 
moderate  pyrexia  was  due  to  an  ordinary  influenza 
nostras,  of  which  the  catarrhal  bronchitis  was  part 
and  parcel. 

Finally,  with  a  clear  impression  of  the  nature  and 
Major  behavior  of  the  aseptic  reaction  in  the  uncomplicated 
Complications  case,  and  of  its  modifications  by  minor  complica- 
tions, the  way  is  open  to  the  further  study  of  the 
influences  which  more  serious  complications  may 
exert. 

In  this  exposition,  I  have  yielded  to  the  tempta- 
tion to  present  a  theory,  incomplete  as  it  is,  and 
still  insufficiently  founded.  In  its  application,  it 
should  not  be  overlooked,  that  it  must  needs  be 
restricted  to  those  cases  which  were  aseptic  and 
afebrile  at  the  time  of  operation.  With  the  proper 
reserve  imposed  upon  it  by  the  cautious  worker,  it 
may  perhaps  be  of  use,  but  it  would  be  unscientific 
and  misleading  to  extend  its  scope  unduly. 

Table  I. 


MEAN  DAILY  RECT. 

AL  TEMPERi* 

lTURES.  pre-operative, 

Case. 

Minimum. 

Maximum. 

Mean. 

p.  R.  3429  C.  V. 

98.6°  F. 

99.4°  F. 

99.0°  F. 

P.  R.  3003  T.  R. 

99.2°  F. 

99.8°  F. 

99.5°  F. 

P.  R.  2010  L.  M. 

'98.8°  F. 

99.0°  F. 

98.9°  F. 

P.  R.  3385  P.  L.  S 

.  98.8°  F. 

99.4°  F. 

99.1°  F. 

P.  R.  3228  C.  W. 

98.4°  F. 

99.6°  F. 

99.0°  F. 

Average 

98.8°  F. 

99.4°  F. 

99.1°  F. 

Guiding  Principles  in  Surgical  Practice     145 
Table  II. 

DAILY  MEAN  TEMPERATURE  IN  ASEPTIC  LAPAROTOMY. 
RECTAL    AND    ORAL    TEMPERATURES     COMPARED. 

Pre-operative  Maximum  P.O.Temp. 

Temperature.  Rise.  2nd  week. 
Rectal  temperature  99.1°  F.  100.6°  F.  98.7°  F. 
Oral  temperature  98.4°  F.  100.3°  F.  98.2°  F. 
Difference  0.7°  F.  0.3°  F.        0.5°  F. 

Table  III. 

RECTAL    AND    MOUTH    TEMPERATURES    IN    THE    SAME 
PATIENT  TAKEN   SIMULTANEOUSLY   NEAR  THE 
END   OF   THE   FIRST   WEEK   AFTER    HYSTE- 
RECTOMY. 


P.R.4558E.K. 

Per  rectum.     Per  os. 

Differeence, 

12  noon. 

100.0°  F.      99.0°  F. 

1.0°  F. 

4  P.M. 

99.8°  F.      99.0°  F. 

0.8°  F. 

8  P.M. 

100.2°  F.      99.2°  F. 
Table  IV. 

1.0°  F. 

THE   MAXIMUM  RISE  AND  THE  TIME  OF  ITS  APPEAR- 
ANCE.      RECTAL    TEMPERATURE. 


Number  of 

Time  of 

Maximum  Hours  after 

Case. 

Operation 

.       Rise. 

Operation. 

P.  R.  3429  C.  V. 

3  P.M. 

101.0°  F. 

29 

P.  R.  2966  K.  H. 

9  P.M. 

100.4°  F. 

12 

P.  R.  3385  P.  L.  S 

;.   3  P.M. 

100.6°  F. 

29 

P.  R.  2010  L.M. 

3  P.M. 

100.4°  F. 

9 

P.  R.  2790  L.  M. 

3  P.M. 

100.4°  F. 

21 

P.R.   695  S.S. 

3  P.M. 

100.6°  F. 

■    9 

P.  R.  2360  J.  T. 

3  P.M. 

101.0°  F. 

13 

P.  R.  2301  N.  P. 

10  A.M. 

100.8°  F. 

21 

Average 

100.6°  F. 

18 

Tables 


146    Guiding  Principles  in  Surgical  Practice 
Table  V. 

MEAN    DAILY    RECTAL    TEMPERATURE,    SECOND    WEEK 
POST-OPERATIVE. 

Case.  Minimum.     Maximum.       Mean. 


P.  R.  3429  C.  V. 

98.0"  F. 

99.4°  F. 

98.7°  F. 

P.  R.  2966  K.  H. 

98.0°  F. 

99.4°  F. 

98.7°  F. 

P.  R.  3003  T.  R. 

98.4°  F. 

99.0°  F. 

98.7°  F, 

P.  R.  2010  L.  M. 

98.2°  F. 

99.4°  F. 

98.8°  F. 

P.  R.  2790  L.  M. 

98.0'  F. 

98.8°  F. 

98.4°  F. 

P.  R.  2360  J.  T. 

98.2°  F. 

99.4°  F. 

98.8°  F. 

Average 

98.1°  F. 

99.2°  F. 

98.7°  F. 

Guiding  Principles  in  Surgical  Practice     147 


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CHAPTER  XIII 


The  Treatment  of  Unclean  Wounds 


Industrial 
Wounds 


The  same  principles  that  hold  good  for  the  clean 
wound  which  is  inflicted  by  the  surgeon  in  an 
aseptic  operation,  are  followed  in  treating  the  ordi- 
nary incised  wound  of  an  emergency  case.  Moisture 
is  congenial  to  bacterial  growth;  and  clean  wounds 
heal  best  when  they  are  kept  dry.  Wounds  received 
in  industrial  accidents  are  usually  more  or  less 
soiled ;  but  the  contamination  is  germless,  or  at  least 
in  most  instances,  contains  no  pathogenic  organisms. 
When  the  grime,  filth,  dirt,  tar,  paint,  axle-grease, 
and  the  like  have  been  removed  from  a  laborer's 
injured  hand,  it  is  not  uncommon  to  see  healing  take 
place  by  first  intention.  A  little  free  bleeding  from 
the  cut  surface  may  be  the  best  lavage  the  wound 
can  receive.  Thorough,  but  gentle  rinsing  with 
warm  boiled  water,  is  an  added  precaution.  The 
wound  is  dried  gently,  strapped,  clamped,  or 
sutured,  according  to  the  indication,  and  a  dry, 
sterile  gauze  dressing  is  sufficient. 

If,  however,  contrary  to  the  impression  conveyed 
by  the  history  of  the  accident,  and  the  appearance, 
character,  and  location  of  the  wound,  after  a  few 
days  have  elapsed,  local  redness,  tenderness,  infil- 
tration of  the  edges,  bacterial  discharge,  or  even 
perhaps,  definite  constitutional  symptoms,  such  as 
headache,  malaise,  fever,  show  it  to  be  infected; 
the  plan  of  treatment  for  unclean  or  septic  wounds 
Wounds  ^^  instituted  at  once.  In  fact,  whenever  the  char- 
acter of  the  wound  appears  doubtful,  it  is  an  old 
(154) 


Unclean  and 
Doubtful 


Guiding  Principles  in  Surgical  Practice     155 


but  good  working-rule,  to  treat  it  as  if  it  were 
infected,  until  its  subsequent  behavior  gives  assur- 
ance that  it  is  clean.  The  wound  is  held  agape,  and, 
after  thorough  rinsing,  drains  are  introduced  and 
in  contradistinction  to  the  treatment  of  clean 
wounds,  a  zvet,  mildly  antiseptic  dressing  is  applied. 

Tissue-disinfection,  that  is  destruction  of  bacteria 
by  powerful  germicidal  solutions,  such  as  formalin, 
carbolic  acid,  bichloride  of  mercury,  as  it  was  for- 
merly practiced,  should  be  abolished  in  the  routine 
care  of  unclean  wounds.  It  is  a  different  matter 
when  there  is  reason  to  suspect  inoculation  with  a 
dangerously  pathogenic  organism  such  as  the  tetanus 
bacillus,  as  when  garden-earth  or  soil  has  been  in- 
troduced into  the  wound.  Here  local  sterilization 
must  be  attempted,  even  at  the  risk  of  considerable  Local 
loss  of  tissue.  The  electro-cautory  needle  or  Pac- 
quelin-point  are  probably  most  efficacious ;  next  in 
order,  disinfection  with  pure  carbolic  acid,  which  is 
subsequently  limited  in  its  action  by  the  application 
of  alcohol.  In  either  case,  tetanus  antitoxin  is  in- 
jected circularly  about  the  wound  when  feasible, 
after  a  large  dose — not  less  than  1,500-3,000  units 
— has  been  administered  intramuscularly  in  the 
gluteal  region. 

From  a  practical  point  of  view,  it  is  convenient 
to  think  of  three  stages  in  the  healmg  of  unclean 
wounds.  Firstly,  a  stage  of  infection,  during  which 
the  bacterial  growth  is  progressive,  the  local  in- 
flammation more  or  less  acute.  Secondly,  a  stage  of 
expurgation;  the  extension  of  the  infection  has 
ceased,  acute  symptoms  have  subsided  a"nd  the  dis- 
charge becomes  copious.  Thirdly,  the  stage  of 
aseptic  healing,  when  a  clean,  granulating  surface 
appears. 


Sterilization 


Healing   of 

Uncleein 

Wounds 


156    Guiding  Principles  in  Surgical  Practice 


Stage  of 

Infection 

and 

Sedative 
Dressings 


If,  during  the  stage  of  infection,  the  defensive 
reaction  is  marked,  and  the  inflammation  is  acute, 
the  logical  treatment  is  sedative.  The  most  useful 
of  sedative  measures  in  this  instance  is  the  moist, 
mildly  antiseptic  dressing.  Evaporation  of  the 
moisture  abstracts  heat,  cools  the  surface,  and  makes 
the  patient  more  comfortable.  In  general,  water 
which  has  been  modified  by  the  addition  of  a  mild 
antiseptic,  has  been  used  for  such  dressings,  because 
unmodified  water  has  no  inhibiting  attributes  and 
might  prove  to  be  congenial  to  bacterial  growth. 
How  well  this  practice  is  founded  is  difficult  to  say. 
At  any  rate,  very  mild  antiseptics  such  as  a  one  to 
three  per  cent,  aqueous  solution  of  boric  acid,  while 
still  unfavorable  to  bacterial  development,  are,  at 
the  same  time,  in  contradistinction  to  stronger  an- 
tiseptics, not  particularly  harmful  to  the  living 
tissues  with  which  they  come  in  contact. 

But  the  gauze  dressing  must  not  be  allowed  to  be- 
come dry,  if  its  antiphlogistic  effect  shall  be  pro- 
longed. A  large  dressing  remains  moist  longer  than 
a  scanty  one.  When  frequent  renewal  of  the  dress- 
ing is  out  of  the  question,  because  it  is  impracti- 
cable, as  in  the  large  number  of  dispensary  patients ; 
the  dressing  may  be  kept  moist  in  the  intervals  by 
the  external  application  of  weak  solutions  of  boric 
acid,  boro-salicylic  acid  or  aluminum  acetate.  An- 
other method  is  based  on  attempts  to  retain  the 
moisture  by  restricting  surface  evaporation — the 
wet  gauze  is  covered  with  rubber  tissue  or  other 
material  which  is  impermeable  to  air.  To  me,  the 
correctness  of  this  procedure,  in  the  case  of  an  acute 
inflammation,  is  not  thoroughly  apparent;  for  not 
infrequently,  instead  of  being  antiphlogistic  and  se- 
dative, such  a  dressing  on  its  removal  is  found  to 


Guiding  Principles  in  Surgical  Practice     157 


be  warm  and  distressing  from  the  retention  of  heat 
and  foul  exhalations. 

If,  during  the  stage  of  infection,  the  defensive 
reaction  is  sluggish,  the  inflammation  is  subacute 
or  chronic,  measures  tending  to  awaken  greater 
healing  response,  stimulant  procedures,  are  in  place. 
In  this  connection,  the  stimulant  effect  of  chemicals 
on  living  tissue  has  to  be  considered.  With  chemical 
substances  the  stimulation  may  even,  to  some  degree, 
be  selective.  Thus,  various  aniline  dyes  are  used 
to  stimulate  epithelialization ;  while  gauze,  impreg- 
nated with  red  wash,  and  similar  solutions,  for 
example,  appears  to  influence  more  specifically  the 
connective  tissue  containing  granulations,  which 
make  up  the  body  of  the  wound.  More  recently, 
experiments  on  tissue  hyperplasia  and  tumor  gene- 
sis, have  brought  to  light  the  fact  that  innumerable 
chemical  bodies  may  act  as  tissue  activators. 

No  doubt  the  relative  inconvenience  of  applying 
certain  physical  agents,  such  as  dry  heat  from 
electric  lamps,  or  baking,  has  been  in  the  way  of 
their  wider  adoption  in  the  treatment  of  sluggish 
wounds.  In  the  main,  the  utilization  of  dry  heat  is 
more  in  accord  with  the  general  principle,  that  the 
healing  wound  should  be  kept  dry.  Here  the  mace- 
ration which  is  produced  by  wet  procedure,  some- 
times proves  to  be  an  undesirable  complication. 
Thus  the  stimulant,  poulticing  effect  of  a  moist 
dressing  covered  with  rubber  tissue,  in  conjunction 
with  prolonged  hot  bathing  of  the  part,  is  contra- 
indicated  in  the  treatment  of  a  wound  in  the  dia- 
betic patient.  Moreover,  in  every  instance,  it  must 
be  borne  in  mind  that  where  the  diminished  healing- 
activity  is  due  to  a  constitutional  cause,  no  amount 


Stage    of 
Infection  and 
Stimulant 
Treatment 


Constitutional 
and  Local 
Causes  of 
Sluggish 
Healing 


158     Guiding  Principles  in  Surgical  Practice 

of  local  stimulation  alone,  even  after  the  wound  has 
become  clean,  will  suffice  to  bring  about  a  better 
healing  response.  Furthermore,  there  may  be  a 
regional  peculiarity,  as  in  varicose  veins  of  the  legs. 
When  a  wound  is  inflicted  in  the  compass  of  the 
pigmented  area,  it  does  not  heal  readily,  because  of 
the  pathological  vascular  condition  of  the  part.  Tis- 
sue activators,  or  physical  agents,  can  contribute 
very  little  towards  wound-healing,  if  the  other,  more 
important  measures,  directed  towards  emptying  the 
capillary  veins,  are  disregarded. 

With  the  arrest  in  the  further  progress  of  the 

infection,  the  defensive  reaction  begins  to  dominate, 

and   the   wound-discharge   becomes   more   copious. 

Wound-discharge  is  the  result  of  an  effort  of  the 

Stage  of    wound  to  expurgate  itself.     It  represents  the  mass 

lixpurga  ion   ^£  demarcated  and  softened  tissue  about  the  bac- 
and  Wound 
Discharge  Serial  focus — a  germ-laden,  fluid  debris  which  should 

not  remain  occluded.  Its  presence  excites  exuber- 
ant granulations,  which  disappear  when  the  wound 
is  kept  clean  and  dry. 

When  the  wound  is  shallow,  and  above  all,  when 
the  wound-discharge  is  scanty,  there  is  no  dress- 
ing which  is  better  adapted  to  bring  the  wound 
into  a  healthy  condition  than  plain,  dry,  loosely 
woven,  aseptic  gauze.  Occasionally,  for  practical 
reasons  only,  when  a  wound  cannot  be  dressed 
as  soon  as  it  should  be,  or  the  discharge  decomposes 
with  exceptional  readiness,  a  dry  antiseptic  gauze 
may  be  substituted  for  the  aseptic  dressing;  or,  a 
dry  deodorant  gauze,  when  the  discharge  is  foul 
and  disturbing  to  the  patient. 

When,  however,  during  the  stage  of  expurgation 
of  the  wound,  the  focal  accumulation  of  pus  is  more 


Guiding  Principles  in  Surgical  Practice     159 


or  less  deepseated,  and  the  discharge  is  profuse,  the 
gauze  drain  is  often  of  itself  unsatisfactory  for  the 
purposes  of  drainage,  and  adjunct  measures  become 
necessary,  such  as  the  use  of  the  wound-wedge,  rub- 
ber tubes,  or  loop-drains  of  wire  or  metal.  The 
reason  why  dry  gauze  when  employed  as  a  drain  is 
not  trustworthy  in  this  instance,  is  because  its  fine 
meshes  are  rapidly  clogged  by  fhe  inspissated  dis- 
charge. Thus,  not  infrequently,  what  was  intended 
to  facilitate  drainage,  really  impedes  it,  by  clogging 
the  wound-outlet  like  a  stopper.  The  clinical  pic- 
ture is  that  of  retention,  and  when  the  gauze  is  re- 
moved the  incarcerated  pus  pours  from  the  wound. 
Since  the  inspissation  of  the  discharge  in  the 
dressing  is  due  to  the  evaporation  of  its  water  con- 
tent, it  is  true,  gauze  drainage  can,  where  this  is  in- 
dicated, be  promoted  by  the  use  of  wet  gauze,  and 
by  excluding  the  air  by  means  of  rubber  tissue  to 
prevent  evaporation,  or  by  the  continued  external 
application  of  moisture — methods  which  are,  how- 
ever, far  from  being  ideal.  In  large  wounds  the  dif- 
ficulty is  overcome  by  the  introduction,  in  conjunc- 
tion with  the  gauze,  of  two  or  more  soft  rubber 
tubes  with  a  number  of  lateral  openings.  In  small 
wounds  the  problem  assumes  a  different  aspect.  In 
order  to  preclude  retention  in  these  cases,  a  twirl  of 
gauze  or  rubber  tissue  may  be  placed  in  one  angle  of 
the  wound.  This  is  intended  to  act,  not  as  a  drain, 
in  the  strict  sense  of  the  word,  but  rather  as  a  wedge 
which  keeps  the  wound  open.  Unfortunately  this 
procedure  promises  more  in  theory,  than  its  adop- 
tion actually  merits  in  practice.  The  small  incision 
is  apt  to  collapse  at  the  side  of  the  drain;  perhaps 
before  the  bandage  is  applied,  there  exists  some 
uncertainty  whether  it  has  not  already  been  dis- 


Devices  for 

Aiding 
Drainage 


Rubber  Tubes 


160     Guiding  Principles  in  Surgical  Practice 

lodged  by  the  premature  activity  of  the  awakening 
patient. 

It  is  er.sential  that  a  device  for  keeping  small 
incisions,  wounds  and  sinuses  patent,  shall  not 
only  be  slight  in  bulk,  so  that  it  does  not  obstruct 
the  path  of  the  discharge,  but  also  of  such  con- 
struction, that  it  can  be  applied  with  precision  and 
is  not  easily  displaced.  There  is  a  large  class  of 
cases,  in  which  the  insertion  of  a  drain  according  to 
the  usual  methods  is  thoroughly  unsatisfactory;  of 
these  the  unfortunate  with  a  suppurative  teno- 
synovitis and  many  small  incisions  in  the  hand,  is 
but  one  example.  A  simple,  practical  method  of 
draining  such  wounds  consists  in  the  introduction 
into  the  wound  to  the  desired  depth,  of  loop-drains 
of  thin,  flexible  metal. 
Loop  Drains  These  drains  are  nothing  more  than  variously 
shaped  metal  loops  with  flanged  ends.  The  loop  is 
inserted  into  the  recess  to  be  drained,  and  keeps  it 
open  by  virtue  of  the  spring-like  action  of  the  metal. 
The  grooved  flange-ends  grasp  the  sides  of  the 
incision,  and  retain  the  drain  in  place.  It  is  prac- 
tical to  keep  various  sizes  sterilized  and  in  readiness 
for  use;  also  some  narrow  strips  of  metal,  ^th 
inch  wide  and  upward,  in  case  an  anomalous  cavity 
requires  that  one  be  improvised.  This  is  easily 
done  if  the  material  is  thin  commercial  "tin."  All 
that  is  needed  is  a  straight  scissors,  and  an  ordinary 
pair  of  thumb  forceps — instruments  which  are  at 
hand  at  every  dressing.  A  long,  bent  loop-drain 
may  also  be  used  in  the  reversed  way  in  a  sinus 
which  is  difflcult  to  drain  an'd  treat  from  the  bottom. 
With  one,  properly  applied,  it  is  easier  to  irrigate 
the  sinus  and  to  introduce  disinfectant,  antiseptic, 
or  tissue-activating  fluids.     When  a  fluid  is  to  be 


Guiding  Principles  in  Surgical  Practice     161 


retained  in  the  sinus  it  is  less  difficult  to  insert  a 
plug  into  the  opening  between  the  metal  flanges. 
In  applying  the  drain  the  loop  is  simply  closed  by 
nearing  the  flanges  to  each  other,  and  introduced 
into  the  wound  by  means  of  the  thumb  forceps. 
The  loop  is  then  opened  until  the  lips  of  the 
wound  are  sufficiently  separated. 

The  rubber  tube,  as  well  as  the  metal  loop-drain, 
both  serve  the  purpose  of  keeping  the  wound  open, 
while  the  gauze  dressing  itself,  by  virtue  of  its 
capillarity  absorbs  the  discharge  as  it  escapes  from 
the  wound.  In  some  regions,  as  for  example,  in 
the  ischiorectal,  it  is  exceptionally  important  that 
the  draining  wound  be  widely  opened,  lest  the  pus 
burrows  in  various  directions  from  its  original 
focus,  and  ischiorectal  sinuses  and  fistulae  result. 

In  the  appendicitis  abscess,  when  the  patient,  as 
is  often  the  case,  lies  on  the  back,  it  is  the  chemical 
tension  alone  that  causes  the  pus  to  rise  in  the 
wound,  or  in  the  rubber  tube  which  has  been  in- 
serted into  it  for  drainage.  In  this  instance,  the 
wound-discharge  rises  against  gravity  until  the 
wound  is  filled,  when  it  overflows  into  the  gauze 
dressing.  If  the  tube  which  was  intended  to  help 
drainage,  projects  more  or  less  vertically  beyond  the 
wound,  as  such  drains  generally  do,  the  pus  which  it 
contains  is  simply  occluded,  and  cannot  even  escape 
by  overflow,  since  the  end  of  the  tube  is  above  the 
niveau  of  the  pus  in  the  wound  cavity.  In  other 
words,  under  such  conditions,  the  tube  instead  of 
being  helpful,  is  actually  a  disadvantage  in  drainage. 

It  is  clear  from  this  consideration,  that  drainage 
produced  by  chemical  tension  alone,  is  a  drainage 
by  overflow  and  not  a  drainage  from  the  bottom  of 
the  wound.     Chemical  tension  alone,  therefore,  is 


Drains  Should 
Keep  the 
Wound    Open 


The  Role  of 

Chemical 

Tension 


Gravitation 


162     Grinding  Principles  in  Surgical  Practice 

insufficient  to  keep  the  wound  dry.  Should  it  now 
be  possible  to  change  the  existing  conditions,  so 
that  the  forces  of  gravity  may  aid  chemical  tension, 
the  problem  of  evacuating  the  residual  pus  will  find 
a  simple  solution.  Thus,  if  an  ordinary  bottle  with 
a  constricted  neck  were  to  represent  the  abscess- 
cavity,  and  the  water  in  this  container  the  discharge, 
the  easiest  way  of  emptying  it  is  plainly  by  allowing 
the  force  of  gravity  to  act  directly;  the  bottle  is 
turned  so  that  its  neck  descends  below  the  fluid  level. 
Similarly,  gravity  may  be  made  to  assist  drainage, 
when  the  wound-opening  is  brought  to  a  lower  level 
by  postural  changes  of  the  patient.  When  this  is 
done,  the  rubber  tubes  which  were  previously  de- 
funct, begin  to  drain  the  recesses  into  which  they 
have  been  placed;  the  drainage,  instead  of  being 
simply  by  overflow,  takes  place  from  the  bottom 
of  the  wound. 

It  is  because  of  the  prime  importance  of  gravita- 
tion in  the  expurgation  of  the  unclean  wound  that, 
unless  anatomically  or  otherwise  contraindicated, 
the  surgeon  always  opens  and  drains  a  suppurating 
cavity  at  its  most  dependent  point.  Unfortunately 
the  force  of  gravitation  cannot  always  be  made  to 
influence  drainage  directly  by  low  incision  or  the 
requisite  postural  change.  In  such  a  case,  particu- 
larly when  the  cavity  is  deep  and  discharges  pro- 
fusely, removal  of  the  residual  pus  by  drainage  in 
an  uphill  direction  must  be  considered. 

First  of  all,  come  the  methods  by  which  this  is 
attempted  by  continuous  siphonage.  The  laws  un- 
derlying drainage  by  siphonage,  can  be  illustrated 
by  means  of  a  bottle  containing  water  and  a  long 
drainage  tube.  As  the  tube  rests  upon  the  edge  of 
the  bottle,  one  end  immersed  in  the  water,  while 


Guiding  Principles  in  Surgical  Practice     163 

the  other  is  outside,  an  ascending  limb  within,  and 
a  descending  limb  of  the  drainage  tube  without,  „.  , 
may  be  distinguished.  But  in  spite  of  the  fact  that 
the  end  of  the  descending  limb  is  considerably  lower 
than  the  level  of  the  fluid  within  the  bottle,  no 
drainage  takes  place.  Suction,  or  more  accurately 
speaking,  the  production  of  negative  pressure 
within  the  tube  sufBcient  to  raise  the  column  of  wa- 
ter to  its  highest  point  over  the  edge  of  the  bottle, 
is  essential  to  start  the  flow.  When  the  water  has 
once  reached  the  descending  limb,  it  readily  escapes 
by  'gravitation.  But  the  gravitating  column  pro- 
duces renewed  suction  behind  it,  which  causes  a 
second  charge  of  fluid  to  rise  in  the  tube.  Thus 
siphonage,  once  instituted,  may  continue  indefinitely 
until  the  bottle  has  been  emptied  of  its  contents. 

If,  in  such  an  experiment,  the  tube  is  replaced  by  a 
piece  of  gauze,  similar  observations  can  be  made. 
The  drain  may  remain  indefinitely  without  causing 
a  flow  of  fluid  from  the  bottle.  The  capillary  at- 
traction of  the  gauze  alone  is  insufficient  to  carry 
the  water  to  a  point  where  gravity  can  begin  to  act. 
If,  however,  suction  is  started,  by  pouring  water 
down  the  descending  limb,  siphon-action  can  be  ini- 
tiated which  continues  until  the  bottle  is  empty. 
Unfortunately,  these  laws  of  drainage,  striking  as 
they  may  be  in  the  experiment,  have  but  a  very  lim- 
ited application  in  surgical  drainage.  Most  devices 
in  which  siphonage  is  produced  by  running  water, 
or  by  means  of  an  interpolated  rubber  bulb,  or  large 
reservoir  from  which  the  air  has  been  exhausted, 
and  which  have  for  their  object  continuous  drainage 
in  the  strict  sense  of  the  word,  are  anything  but 
practical.  The  ordinary  suction  cup,  it  is  true,  may 
be  kept  on  a  discharging  wound  for  a  long  time; 


164     Guiding  Principles  in  Surgical  Practice 

but  its  action  becomes  feeble  as  the  vacuum  dis- 
appears. It  is  really  better  adapted  for  inducing 
local  hyperemia,  than  for  encouraging  drainage. 
In  practice,  therefore,  the  disposal  of  the  residual 
pus  in  instances  in  which  uphill  drainage  cannot  be 
avoided,  resolves  itself  into  efforts  at  repeated  and 
thorough  evacuation  at  the  time  of  the  dressing  by 
means  of  one  of  two  simple  methods,  either  suction 
or  expression. 
The  I^  t'^s  expression  method,  the  accumulated  dis- 
Expression  charge  is  emptied  by  gentle  compression  and  manip- 
Method  ulation  of  the  pus  undermined  territory,  by  means 
of  the  fingers  of  the  gloved  hand.  When  properly 
carried  out,  it  is  unattended  by  any  traumatism  to 
the  wound.  In  contra-distinction  to  the  suction 
method,  it  has  the  great  advantage  that  it  is  simpler 
in  execution,  and  no  special  apparatus  is  required. 
The  notion  that  pus  may  in  some  way  be  forced 
into  the  blood  vessels  by  this  procedure,  is  errone- 
ous. With  all  its  simplicity,  it  is  none  the  less  effi- 
cient. It  is  applicable  nearly  everywhere  where  the 
tissues  can  be  grasped  or  manipulated  with  the 
fingers,  and  the  surface  structures  are  not  too  rigid 
and  unyielding. 

In  the  treatment  of  the  non-tuberculous  sub- 
maxillary abscess  which  is  so  common  in  the  im- 
properly cared  for  children  of  the  poor  under  three 
years  of  age,  and  is  due  to  pyogenic  infection 
from  the  mouth,  the  use  of  the  expression  method 
is  typically  illustrated.  A  little  ethyl  chloride 
sprayed  on  the  mask,  or  a  few  drops  of  anaesthol 
or  of  ether,  just  sufficient  for  a  primary  anesthesia ; 
a  small  incision  through  the  skin,  parallel  to  the 
natural  folds  in  the  neck  and  over  the  fluctuating 
point  or  the  spot  of  greatest  softening;  penetration 


Guiding  Principles  in  Surgical  Practice     165 

of  the  soft  parts  and  abscess- wall  bluntly,  by  means 
of  a  small  forceps,  while  the  tissue  is  fixed  between 
the  thumb  and  fingers  of  the  left  hand;  separation 
of  the  blades  of  the  forceps  to  widen  the  opening 
into  the  abscess  cavity;  simultaneous  compression 
or  "milking"  of  the  infiltrated  area  from  without, 
until  no  more  pus  appears ;  insertion  of  a  metal 
loop-drain  to  keep  the  small  opening  patent ;  a  large 
dressing  of  loose  sterile  gauze.  If  expression  has 
to  be  repeated  one  or  more  times  at  subsequent 
dressings,  this  can  be  done  without  causing  much 
pain,  because  the  inflammation  is  no  longer  acute, 
as  when  the  abscess  was  first  incised;  neither  does 
a  forceps  have  to  be  introduced  into  the  wound,  be- 
cause the  drain  keeps  open  the  way  for  the  escaping 
discharge.  In  this  procedure,  the  protective  lining 
of  the  abscess  cavity  is  conserved  as  far  as  possible ; 
indeed,  the  use  of  the  curette  within  any  abscess 
cavity  is  obsolete. 

The  suction  method  varies  widely  in  its  applica- 
tion in  the  hands  of  different  surgeons.  It  seems  ^yr^tu^"*^*^"" 
vital,  that  whatever  device  is  used  for  this  purpose, 
the  degree  of  suction  can  be  regulated  at  will;  for, 
in  the  ordinary  suction  cup,  the  vacuum  is  soon  de- 
stroyed. A  serviceable  mechanism  can  be  impro- 
vised by  pushing  one  end  of  a  rubber  tube  which 
is  about  eight  inches  long  and  has  an  internal  diam- 
eter of  about  ^8  inch,  into  the  open  connecting  arm 
of  a  small  glass  suction  cup;  while  the  other  end  is 
slipped  over  the  air-inlet  arm  of  an  ordinary  suction 
pump,  such  as  is  used,  for  example,  to  create  a 
vacuum  in  the  flask  of  a  Potain  apparatus  for  as- 
pirating the  chest.  The  air-outlet  arm  of  the  suc- 
tion pump  is  left  open.  The  most  useful  cup  for 
routine  work,   is  one  which  measures   about  two 


Method 


166     Grinding  Principles  in  Surgical  Practice 

inches  in  diameter  and  has  the  shape  of  a  minia- 
ture bell-jar  (F.  A.  Eschenbaum,  Bonn).  The  suc- 
tion pump  itself  is  all  metal,  and  every  part  of  the 
apparatus,  tube,  cup  and  pump  can  be  sterilized  by 
boiling  with  the  dressing  instruments.  The  nurse 
manipulates  the  pump  while  the  suction  cup  is  held 
snugly  applied  to  the  surface  over  the  wound  from 
which  the  pus  is  to  be  exhausted.  The  skin  becomes 
hyperemic,  is  drawn  into  the  cup,  and  as  the  vacuum 
is  intensified  by  continued  pumping,  the  discharge 
begins  to  flow  from  the  orifice  of  the  wound.  In  an 
unclean  post-operative  case  where  the  sutures  have 
become  infected  by  the  staphylococcus,  for  example, 
considerable  yellow,  odorless  pus  is  at  first  obtained, 
two  to  four  ounces  perhaps,  while  later  the  wound 
discharge  becomes  scantier,  thin  and  serous,  and 
shreds  of  sloughing  fascia  or  the  black  knots  of 
chromicized  catgut  partly  digested,  may  be  observed 
to  pop  through  the  small  drainage  opening  in  the 
incision-line,  into  the  negative  space,  under  the 
powerful  influence  of  the  suction. 

When  finally  an  unclean  wound  has  expurgated 
itself,  the  discharge  has  ceased,  or  is  scanty  and 
sterile,  and  a  healthy,  granulating  surface  presents. 
The  Stage  of  the  stage  of  aseptic  healing  has  been  reached,  and 
Aseptic  closure  of  the  zvound  by  apposition  may  be  attempt- 
ed, in  the  hope  of  securing  union,  just  as  in  the 
cases  in  zvhich  the  wound  was  clean  from  the  be- 
ginning. 


Healing 


CHAPTER  XIV 

Conclusion 

Ready  and  reliable  surgical  judgment  is  cultivated 
by  repeated  reflection  on  surgical  experiences.  In 
this,  a  common  case  may  sometimes  teach  more 
that  is  of  practical  importance,  than  the  exceptional 
one.  Information  which  is  obtained  from  others 
and  from  books,  is  of  great  value,  but  it  is  very 
often  not  half  so  determining  in  its  influence  on 
surgical  reasoning,  as  one  single  error  which  is  self- 
committed.  If,  in  spite  of  every  preliminary,  the 
surgeon  meets  with  an  unfortunate  experience 
which  is  due  to  an  error  in  his  judgment,  he  cannot 
conscientiously  pass  it  by  without  much  thought. 


(167) 


INDEX. 


-^  Page. 

Abdomial  pads 33 

Manner  of  using 23 

Abscess   evacuation   by   suction 

method   166 

Drainage  by  suction,  appara- 
tus   for 165 

Evacuation  by  the  expression 

method    164 

Cavity,  conserving  the  lining 

of  the    165 

Absorable  sutures 60 

Absorption     of    catgut,     micro- 
scopically     61 

Accidents    during    operation    in 
the      differential      pressure 

cabinet    86 

Adhesion,   peritoneal    51 

Adhesive  belt,  use  of  the 129 

Corset,  use  of  the 129 

Strips  for  skin  repair 69 

Afebrile  periods  in  endocarditis-     3 
Periods  in   thrombophlebtis .  .      3 
After   care   of  a   surgical   case, 
relation  of  the  family  phy- 
sician and  surgeon  in  the.  .111 
Air-embolism  during  operation.. 108 
Alimentary  tract,  bacteria  pres- 
ent in 2 

Anaesthol,     the    administration 

of    75 

The  chemical  nature  of 75 

Chief  failing  in  the  use  of..   79 
Anatomy      of  _    the_  _  semilunar 

hypogastric  incision 87 

Of  the  mesial  rectus  incision.   95 

Anesthesia    74 

With   chloroform    75 

With    chloroforrn,    chief   fail- 
ing in  conducting 79 

With   anaesthol    75 

With  anaesthol,   chief  failing 

in  conducting 79 

Dark  blood  during 80 

Use    of    the    breathing    tube 

during    80 

Cardiac   collapse   during 76 

Abolition  of  hearing  during.  .   77 
Abolition     of     consciousness 

during   77 

Abolition  of  reflexes  in 77 

Coughing    reflex    during 80 

Vomiting  during 80 

Induction  of  shock  during.  .  .    78 
Estimating     the     amount     of 

shock  after 81 

The  pulse  before  and  after..   80 


Page. 

Lime-water  for  nausea  after.  110 
Milk  of  magnesia  for  nausea 

after   110 

Relation    of    diseases    of    the 

heart  to 81 

Epilepsy  in  its  relation  to.  .  .  .    82 

In    tuberculous   subjects 82 

In  diabetic  subjects 82 

With  chloroform  or  ether...  82 
For  operation  on  the  brain..  83 
In    operations   for    tumors    of 

the  larynx 84 

With  the  intratracheal  tube  in 

tumors  of  the  larynx 84 

By   the   intratracheal   insuflfla- 

tion  method    84 

By    the    Meltzer    and    Auer 

method   _. .    84 

In    the    positive    differential 
pressure  cabinet    .........   85 

Relative  value  of  the  intra- 
tracheal insufilation  and 
differential  pressure  meth- 
ods  of    86 

Anesthetic,   disguising  the   odor 

of  the   76 

Anesthetist,  relation  of  the  sur- 
geon to  his 74 

Antiseptic    and    aseptic    wound 

treatment     14 

Appendicitis    and    inguinal    her- 
nia, single  incision  for....    98 
Artery,    deej)    epigastric,    in    in- 
cisions   in   the   lower   abdo- 
men     .•    95 

Articles    for    the    utensil    steri- 
lizer     28 

Asepsis,  logical   1 

Personal    _■ 41 

Aseptic  suture  material 69 

Operation,    fever    after 133 

Fever    curve    133,  136 

Fever     curve,     influence     of 

bowel   stasis  on  the 137 

Fever     curve,     influence     of 

menstruation   on   the 138 

Reaction  is  changed  by  com- 
plications     _ 137 

Stage  in  wound  healing  by- 
secondary  intention,  treat- 
ment during  the ..166 

Asphyxia,    during    intrathoracic 

operation     86 

Assistants,  suggestions  made  by.lOl 
Duties    of 100 


169 


170 


INDEX 


B  Page. 

Bacteria,      in      the     alimentary 

tract    2 

In  the  genito-urinary  tract.  .      3 
In     relation     to     steam     ster- 
ilization         16 

Boiling  time  required  to  de- 
stroy   .    33 

Bacterial,    foci   normally  within 

the  body   2 

Foci  at  the  site   of  disease..      3 
Bare  arms  during  operation....  38 

Basin  for  alcohol 28 

Bath,  effect  on  the  skin  by  the 

cleansing    8 

Interval    after    the 8 

Binder,    the   abdominal 138 

Blood     of     dark     color     during 

anesthesia     80 

Boiling  method  superior  for  in- 
struments and  utensils....    31 
Of  rubber   gloves   in   alkaline 

solution    31 

Method,  time  required  for 
sterilizing     instruments    by 

the 32 

Method,     time     required     for 

utensils  by  the 32 

Bone  healing   49 

Union,  methods  of 69 

Bowel  distension,  hindrance 
during  operation  on  ac- 
count of 104 

Inertia,   postoperative    116 

Evacuation  after  rectal  op- 
eration     131 

Stasis,    influence   on    the   typ- 
ical  aseptic   reaction   by.  ..137 
Brain  operation,  anesthesia  in..   80 
Breathing     tube     during     anes- 
thesia, use  of  the 80 

C 

Calomel  after   operation 133 

Carbon   tetrachloride    8 

Cardiac  collapse    76 

Care  of  the  patient  after  opera- 
tion     110 

Cartilage   healing    48 

Cascara  sagrada  after  opera- 
tion     ...134 

Caster       oil       as       a       routine 

cathartic,  objections  to 131 

Catgut   sutures,   histologically.  .    60 

Sutures,   chemically    60 

Digestion 60 

Suture,     reaction     of    tissues 

towards    .•  •  •  •    61 

Suture      absorption,    _  micro- 
scopic   changes    during....    61 
Sutures,    moisture    starts  ^the 

dissolution    of    _•  •    61 

Resistance,  terms  used  to  in- 
dicate    •.  ■  •   62 

Resistance,  terms  of  relative 
significance  in  the  human 
subject   62 


Page. 

Suture,  actual  period  of  use- 
fulness in  human  tissues  of 
the    63 

Suture,  water  is  essential  for 
action  of  cell  enzymes  on.    64 

Digestion,  extracellular  and 
intracellular     64 

Suture  should  be  aseptic  n'ot 
antiseptic    66 

Suture  resistance  of  "40  and 
60  day"  most  generally  use- 
ful        66 

Suture,  ■  highly  chromicized, 
preferable   to   bulky 65 

In  skin  suture,  objections  to.    68 

Sterility  depends  on  the 
manufacturer    70 

Method  of  sterilization  and 
preservation   of   ,  .    70 

Tubes,  sterilization  of  the 
surface  of   71 

In     sealed     tubes,     effect     of 

boiling  on    71 

Cathartic   diet    119 

Cathartic,  objection  to  caster  oil 

as  a  routine _ 121 

Cathartics    after    operation,    the 

use  of  mild 134 

Cell  functions,  development  and 
decadence   of    45 

Specialization  and  loss  of  re- 
productive  power    45 

Growth    is    not    impaired    by 

specialization    46 

Cells,  highly  specialized,  com- 
pensate  by    growth    not   by 

multiplication   46 

Cell  growth  not  cell  multiplica- 
cation  in  highly  specialized 
cells     46 

Enzymes,  action  on  catgut  by  64 
Chart    I,     schematic    curve     of 
aseptic  fever   ..147 

II,  actual  curve  of  aseptic 
fever    148 

III,  pronounced  effect  of 
bowel  stasis  on  the  aseptic 
reaction .149 

IV,  slight  menstrual  wave  in 
the  aseptic  curve 151 

V,  effect  of  normal  rnenstru- 
ation  on  the  aseptic  reac- 
tion     151 

VI,  influence  of  marked  skin 
infection  on  the  typical 
aseptic  reaction   152 

VII,  influence  of  influenza 
nostras  on  the  aseptic  re- 
action       ; 153 

Chemical  disinfection 5 

Methods    for    sterilization    of 

dressings    14 

Tension,    arainage   by 161 

Chloroform  in  every  day  prac- 
tice,   reasons    for    the    use 

of    75 

Safer  substitutes  for 75 


INDEX 


171 


Page. 
Chief  failing  in  the  use  of. .  79 
Combinations,     chief     failing 

in  the  use  of 79 

Or  ether  for  anesthesia? 82 

Cicatrical    tissue,    slight    resist- 
ance of 57 

Cicatrix,  elastic  fibres  in  the 54 

Cicatrization    undesirable   when 

excessive     53 

Clamps  in  skin  rei)air 68 

Cleansing,  mechanical    5 

Bath   8 

Codeine  phosphate  after  opera- 
tion    112 

Collapse,    cardiac    76 

Of  the  patient  at  operation.. 108 
Combined  methods  of  skin  ster- 
ilization        6 

Incision    for    inguinal    hernia 

and  appendicitis   98 

Comparative   time   required   for 

sterilization     18 

Complications,  deviations  in  the 

aseptic  curve  due  to 137 

Conclusion   167 

Conservative  incision,  the  study 

^      of    87 

Consciousness,   abolition  during 

anesthesia,  of  77 

Considerations,  general 1 

Constipating  diet    120 

Contamination         of         sutures 
through  moist  table  covers.  21 

Contents,  table  of V 

Co-operation  at  operation 2 

Coughing    reflex    during    anes- 
thesia      80 

Course  of  the  operation 100 

Croton  oil  after  operations .122 

Cutting    instruments,     steriliza- 
tion of 34 


D     • 

Death   by   asphyxia   during   in- 
trathoracic operations   ....   86 
Decadence  of  cell  functions...   45 

Delta  sponges    22 

Development  of  cell  function..   45 
Devices      for      aiding      wound 

drainage    159 

Dexterity  in   operating 1 

Diabetes,  relation  of  anesthesia 

to    82 

Diet  after   operation 115 

Liquid,  after  operation 117 

Convalescent,       articles       ex- 
cluded from  118 

Convalescent's 118 

Fats  in  postoperative 118 

Sweets  in  postoperative 118 

Green      leaf      vegetables      in 

postoperative    119 

Cathartic   119 

Constipating  120 

Full,  after  operation 124 


Page. 

Vegetable   as   opposed   to   an- 
imal     124 

I'lic  normal 124 

Postoperative  full 124 

Differential      pressure     cabinet, 

anesthesia   in 85 

Difficulty     in     urination     after 

operation    113 

Digestion   of  catgut 60 

Of   catgut,    extracellular   and 

intracellular     64 

Dionine  after  operation 112 

Discharge     status     in     surgical 

cases     132 

Discharging  wounds 158 

Wounds,    drainage    of 159 

Disease,  of    the    heart,    relation 

of  anesthesia  to 81 

Disguising  the  odor  of  the  an- 
esthetic        76 

Disinfection,  chemical   5 

Of  wounds   155 

Dissection   in    operating 103 

Doubtful  wounds    154 

Douche,  vaginal,  with  iodine..   13 

Vaginal,  with  tannic  acid 13 

Vaginal,   with   lysol    13 

Drainage  of  discharging 

wounds    158 

Of  unclean  wounds 159 

Of   wounds,   devices   for   aid- 
ing     159 

Of     wounds     by     means     of 

rubber   tubes    159 

Of  small   wounds 159 

With    loop-drains    160 

Factors   in    161 

By   chemical    tension 161 

By    gravitation    ._ 162 

By   continuous   siphonage. .  ..163 

Drains,   the   use   of 129 

General  object  of 161 

Dressing  materials  for  wounds.  14 
Rotation  in  operating  room..  38 
After  operation,  the  first... .128 
Wounds  with  silver  leaf....  129 

In  clean  cases 130 

Discarding   the    130 

dressings,  the  use  of  the  pubic 

strip  in    127 

Use  of  laparotomy  straps  in.  127 
Use  of  adhesive  corset  in...  128 
During    the    stage    of    infec- 
tion,   sedative    156 

During    the    stage    of    infec- 
tion,   stimulant    157 

Dressing,    stimulant    157 

Drugs,  cathartic 121 

Drying,_   effect    of    on    tetanus 

bacilli   produced  by 33 

Duties   of   first   and    second   as- 
sistants _ 100 

Of  operating  room  nurse....  101 
Of    the    surgeon^  toward    the 
family    physician     on     dis- 
charging  a    case 132 


172 


INDEX 


^  Page. 

Elastic  fibre  in  fasciae 64 

Fibres  jn   ligaments 54 

Fibres  in  the  skin 56 

Fibres  scanty  in  scars 64 

Fibres?  Does  exercising  a 
young  scar  help  the  devel- 
opment  of    58 

Fibres,  theory  of  the  signi- 
ficance of   54 

Embolism  during  operation. ..  .108 
Emergency  preparation  for  op- 
eration  _ 10 

Endocarditis    with    afebrile    pe- 
riods         3 

Enemata,  postoperative  use  of.l23 
After    operation    for    the   re- 
moval  of  gas Ill 

After  operation  for  the  evac- 
uation of  the  bowel 183 

Enzymes,   action   on   catgut   by 

cell    64 

Epilepsy,  relation  to  anesthesia  ■ 

of    S3 

Epithelialization     63 

Ether  feeding   76 

Or  chloroform  for  anesthe- 
sia?   82 

Evacuating  pus  by  the  suction 

method     165 

Evacuation   of  pus  by  the  ex- 
pression method    164 

Eixpression  method  for  evacuat- 
ing i)us   164 

Expurgation  of  the  wound....  158 
Extension    of    McBurney's  _  in- 
tramuscular incision. 

Weir's    98 

Extrinsic    infection 2 

Infection,    sources    of 40 

F 

Fainting  at  ojjeration 107 

Family    physician    in    his    rela- 
tion   to    the    postoperative 

treatment    HI 

Physician,      after     discharge, 
surgical  cases  report  to.. .132 
Facial  structures,  role  of  elastic 

fibres  in   .••;••   5* 

Fat  solvent  menstruum,  iodine 

in  a   8 

Solvent    property    of    carbon 

tetrachloride     8 

Fatty  nature  of  sweat 9 

Fever,  preoperative   3 

Aseptic    133 

Curve,  the  aseptic 133,136 

Curve,     influence     of     bowel 

stasis  on  the  aseptic 137 

Curve,  influence  of  menstrua- 
tion on  the  aseptic 151 

Curve,  influence  of  influenza 

nostras  on   the  aseptic. ..  .158 
Curve,    influence    of    a    skin 
infection  on  the  aseptic. .  .152 

Foci,   latent   bacterial 3 

Food,  cathartic   119 


Page. 
Constipating     120 

Full  diet  after  operation 124 

Function    of    the    cell,    develop- 
ment and  decadence  of  the  45 
Functional     compensation  _  and 
scar    formation    are    inde- 
pendent     47 

G 

Gas  pain  after  operation. ....  .111 

Gauze     sterilized    by    chemical 

means 14 

Sterilized   by   heat 14 

Sponges    21 

Tampons     22 

Tampons,  the  use   of 23 

Pads,  the  use  of 23 

Required    for    cleansing    the 

skin  for  operation 24 

General  considerations    1 

Preparation  of  the  patient...     5 
Genito-urinary     tract,     bacteria 

present    in    2 

Germicides  in  wound  treatment.  14 

Glove,   the   half- 42 

Gloves,   sterile    20 

Sterilization  of  17,39 

Wet  or  dry? 38 

Objections   to   wet 38 

Disposal   of  soiled 17 

Objections   to    41 

Are  indispensable  43 

Gowns,   sterilized    19 

Granulation  of  surface  wounds.  52 

Granulations,  exhuberant    53 

Gravitation,  drainage  by 162 

H 

Half-glove,    indication    for    the 

use  of  the   42 

Pattern   for  the    42 

Handing    sponges    to    the    sur- 
geon     22 

Hands,    the    surgeon's 36 

Cannot  be  sterilized 36 

Should     be     protected     from 

pus    •  40 

Provision    for    cleansing    of 

the    28 

Preoperative  preparation  of. .   37 

Hartley   table    .••••:•   ^1 

Healing,  role  of  connective  tis- 
sue  in    47 

Healing  of  cartilage 48 

Of  bone    49 

Of  striated  muscle 49 

Of  smooth  muscle 50 

Of  heart  muscle 50 

Of  nerve  tissue 51 

Of   the    peritoneum 51 

Of  the  parenchyma  of  secret- 
ing organs   52 

Of  surface  wounds  by  granu- 
lation      53 

Wounds,     elastic     fibres     ap- 
pearing in    54 


INDEX 


173 


Page. 
Of     unclean     wounds,     three 

stages  in 155 

Of  unclean   wounds,  stage  of 

infection  in   156 

Of  unclean  wounds,  stage  of 

expurgation    in    the 158 

Of  unclean  wounds,  the  asep- 
tic stage  in 166 

Constitutional  causes  of  slug- 
gish      157 

Local  causes  of  sluggish 157 

Hearing  abolishes  during  anes- 
thesia       77 

Heart  muscle,  healing  of 50 

Disease,   relation   of  anesthe- 
sia to    81 

Hemorrhage    during    an    opera- 
tion    108 

Hemqstasis,  reliable 102 

Hernia  and  appendicitis,  single 

incision   for    98 

Hypertrophy  not  hyperplasia  of 
highly       specializecf      cells, 
compensate  a  loss  of  tissue.  46 
Hypogastric  incision,  the  semi- 
lunar  87 


.  I 

Illustrations,  Chart  I,  schematic 
curve  of  aseptic   fever.,.. 147 

Chart  II,  actual  curve  of 
aseptic   fever    148 

Chart  III,  effect  of  marked 
bowel  stasis  on  the  aseptic 
reaction     149 

Chart  IV,  small  menstrual 
wave  appearing  in  the 
aseptic  curve   150 

Chart  V,  effect  of  normal 
rnenstruation  on  the  asep- 
tic  curve    151 

Chart  VI,  influence  of 
marked  skin  infection  on 
the  postoperative  tempera- 
ture     152 

Chart  VII,  minor  complica- 
tion due  to  influenza  nos- 
tras      153 

Illustration     of    the     surgeon's 

half-glove     42 

Impermeable   wound   dressings.    25 

Inanition   before   operation 116 

Incision     87 

The   semilunar   hypogastric. .   87 

In  the  lower  abdomen,  other 
methods  for   95 

The_  mesial   rectus 95 

Indications  for  the  mesial 
rectus    97 

In  the  upper  abdomen,  rout- 
ine    97 

The    right    rectus 98 

McBurney's  instramuscular. .   98 

For  inguinal  hernia  and  ap- 
pendicitis       98 

Choice  of   99 


Page. 

At   the   lowest  point   is   help- 
ful   in    drainage 162 

Incisions,   practical    87 

Special    98 

Incompatibility      between      skin 

secretion   and    disinfectant...      8 
Indications   for   using  absorable 
and    inabsorable   sutures...   67 
For    the    mesial    rectus    inci- 
sion       97 

Industrial   wounds    154 

Infection,    extrinsic    2 

Intrinsic    2 

The  stage  of   156 

Souxces   of  wound 40 

Infections,     influence    of    post- 
operative skin    140 

Influenza    nostras    after    opera- 
tion      143 

Instrument   table    21 

Sterilizer     33 

Instruments   are   best  sterilized 

by    boiling    _.  _. 31 

And      utensils,      sterilization 

of    27 

Insufflation    narcosis,    intratra- 
cheal      for       intrathoracic 

operations 84 

Intramuscular  incision,  McBur- 
ney's      98 

Interval  after  the  bath 8 

Intrathoracic    operations,    anes- 
thesia in   ._ 84 

Intratracheal     narcosis     in     tu- 
mors  of  the  larynx 84 

Intrinsic   infection    2 

Iodine-soapsuds  sequence   6 

Method,  radical 6 

In   fat-solvent  menstruum....     8 

For  vaginal  douche 13 

Irrigator   apparatus   in   the   op- 
erating room   29 

J 

Judgment,  surgical    1 

The  basis  of  surgical 167 


K 

Kammerer's    rectus    incision... 


L 

La  Grippe  after  operation 143 

Laparatomy   sheet,    sterile 20 

Straps,  use  of 127 

Larynx,    narcosis    in    operating 

on  the   . ._ .." 84 

Latent  bacterial  foci  •  •  •  •_ 3 

Ligaments,   elastic  fibre  in 55 

Linen    thread    for    hollow    or- 
gans  68 

Objectionable  in  skin  suture.   68 
Liquor   disinfectans    7 

Expurgans    7 


174 


INDEX 


Page 
Local    preparation    of    the    pa- 
tient       6 

Logical  asepsis    \ 

Loop-drains    160 

Loose  aseptic  gauze  for  cover- 
ing wounds    84 

Low     incision     is     helpful     in 

drainage    162 

Lysol  for  vaginal  douche 13 


M 
Magnesium  citrate  after  opera- 
„    tion   124 

Major    complication,    influence 

on  aseptic  reaction  by  a... 144 
McBurney    intramuscular    inci- 
sion       98 

Mechanical   cleansing    5 

Menstruation,  influence  on  the 

typical  reaction  by 138 

Metal  clamps  in  skin  repair. . .   68 

Drains  for  small  wounds. ..  .160 
Method,   sirnplified  cleansing.. 7,  10 

Of  simplified  cleansing,  as 
substitute    for   disinfection.  10 

The  iodine-soapsuds  6 

The  radical  iodine 10 

Of  emergency  preparation  of 
skin 11 

Of  emergency  preparation  of 
the  skin  with  aqueous  lysol  11 

Of  emergency  preparation  of 
the  skin  with  iodine 11 

Of  emergency  preparation  of 
the  skin  with  soap  and  wa- 
ter       11 

Of  preparing  the  skin  for 
operation,  the  combined...     6 

Of  preparing  the  skin  for 
operation,   a  new  combined     7 

Of  sterilizing  utensils  by 
boiling    SI 

Of  sterilizing  instruments  by 
boiling   31 

Of  sterilizing  rubber  gloves..  39 

Of  sterilizing  and  preserving 
catgut    ,_ 70 

Of  preparing  the  hands  be- 
fore operating 37 

Of  anesthesia  in  operation  on 
the  brain_ 83 

Of  evacuating  pus  by  expres- 
sion     _. 164 

Of  evacuating  pus  by  suc- 
tion     165 

Methods  of  sterilizing  the  skin, 
combined   6 

Of  sterilizing  gauze  by  chem- 
ical means    H, 

Of  sterilizing  gauze  by  means 
of  heat    14 

Of  uniting  bone   69 

Michel's   clamps  _ 68 

Minor    complications,    influence 

on  the  aseptic  reaction  by.  137 
Mixed  diet  after  operation. ..  .124 


Page 
Moisture   starts   catgut   dissolu- 
tion       61 

Morphine  after  operation Ill 

Mucous     membranes,     prepara- 
tion for  operation  of  the. .   11 
Preparation   with  tincture  of 

iodine 10, 11 

Preparation  with  tannic  acid  11 

Preparation   with   lysol 11 

Preparation    with    soap    and 

water  n 

Muscle,  Healing  of  smooth....    50 

Healing  of  striated 49 

Sheath,  elastic  fibres  in  the.   55 

N 

Nausea,    eflfect    of    lime    water 

on   post-operative    110 

Effect    of    milk    of   magnesia 

on   post-operative    110 

Needles,  choice  of 105 

Qassification   of   105 

Nerve  Tissue,  the  healing  of . .   51 
New  combined  method  of  skin 

sterilization 7 

Nurse's   outline   of   preparation 

for  operation 12 

List     of     supplies     for     one 

laparotomy   26 

List  of  articles   to  be  boiled 

in  the  utensil  sterilizer. ...   30 
Duties      in      the      operating 

room    101 

Fainting  at  operation 107 

O 

Object  of  gauze  dressing 24 

of  sutures 59 

Objection    to   bare   arms   while 

operating   38 

Objections  to   methods  of  skin 

sterilization 6 

To  wet  gloves 38 

Odor    of    the    anesthetic,    dis- 
guising the 76 

Oil  of  rose  to  disguise  the  odor 

of  anesthetics    76 

Oleum  _  tiglii  after  operation . . .  122 
Operating  table  with  sterilizable 

top 27 

Room   utensils,   classified....   28 

Room  nurse,_  duties  of. .....101 

Room,  dressing  rotation  in . .   38 

Rules   for  safe 4 

Room,  arrival  of  the  patient 

from  the   110 

Operation,    Preparation    of   the 

patient  f or_ 5 

Nurse's    outline    of    prepara- 
tion for 12 

Inanition  before  ••_.... 116 

Advantage  of  nourishing  the 

patient  well  before 116 

Co-operation  at 2 

Family  physician  at 102 


INDEX 


175 


Page 
Provision    for    cleansing    the 

hands  at   28 

Basins  for  sterile  water  at..   28 
Provision  for  septic  fluids  at  30 
The  choice  of  needles  for... 106 
Accessories      necessary      for 
soap    and    water    cleansing 

of  the  field   of 38 

Division  of  labor  at 100 

Difficult  exposure  on  account 

of  distended  bowel  during.  104 
Retraction    and    handling    of 
vulnerable    structures    dur- 
ing     104 

Walling  off  pus  foci  during..  106 

Safe  hemostasis  at 104 

Avoidance       of       stagnating 

fluids  at  the  site  of  the... 107 
Unnecessary    dissection    dur- 
ing     102 

Course  of  the 100 

Fainting  of  a  nurse  at 108 

Severe     hemorrhage     during 

an    108 

Collapse   of  the  patient  dur- 
ing     108 

Air   embolism    during 108 

On  the  brain,  anesthesia  dur- 
ing       83 

For  tumors  of  the  larynx,  an- 
esthesia in ,_. . ,   84 

Anesthesia  in  intrathoracic.   84 
With   anesthesia  in  the  posi- 
tive,    differential     pressure 

cabinet 85 

Death  during  intrathoracic. .   86 
Care  of  the  patient  after.... 110 
Relations  of  the  family  phy- 
sician and  surgeon_  after.  .111 
Anodynes    and   somnifacients 

after     112 

Morphine  after  Ill 

Causes  of  wakefulness  after.  112 

Gas   pain   after Ill 

Enema   for  expelling  gas  af- 
ter ......_ Ill 

Bowel  inertia  after 116 

Enemata  after 123 

Enema     for     evacuating    the 

bowel  after   123 

Difficulties  in  urination  after.113 
When  to  catheterize  after... 113 
Record    of    the    quantity    of 

urine  after  114 

Suppression  of  urine  after..  115 

Urme  analysis  after 114 

Factors  concerned  in  the  gas- 
tric upset  after 115 

Diet  after  115 

Liquid  diet  after 117 

Convalescent  diet  after 118 

Full  diet  after 124 

Avoiding  excess   of  fats  and 

sweets  after    118 

Cathartic   food  after 119 

Constipating  food  after 120 

Mild  cathartics  after 124 

Caster  oil   after 121 


'  '  ,.  Page. 

Croton   oil  after i22 

Calomel  after   .'.123 

Use  of  opiates  in  rectal  cases 

after     j20 

Constipating  the   bowel   after 

„''e'^tal     .,.. 120 

Evacuating    the    bowel    after 

rectal   121 

Changes  of  position  after.  126 

Aseptic   fever   after 133 

Interpretation  of  fever  after.133 
Influence  of  menstruation   on 

the   fever  curve  after 138 

During  menstruation,  influ- 
ence on  the  aseptic  reac- 
tion in 139 

Influence   of  bowel  stasis  on 

the  curve  after 137 

Influence  of  a  slight  skin  in- 
fection on  the  reaction  af- 
ter    140 

Influence  of  a  marked  skin 
infection    on    the    reaction 

^after 140 

Effect  of  influenza  nostras  on 

the  reaction  after 143 

Pubic  strip  for  dressing  after 

gynecological    127 

Use  of  laparotomy  straps  af- 
ter      127 

Use  of  adhesive  corset  after..  128 
Use  of  the  adhesive  belt  af- 
ter    128 

The  abdominal  binder  after.. 128 
Rupture  of  suture  line  after. 128 

The  use  of  drains  after 129 

The  first  dressing  after 128 

Dressing   of   the  wound   with 

silver  leaf  after 129 

Sitting   up   after 131 

Second  week  after 127 

Temporary     support     of     the 

_  young  scar  after 130 

Opiates  in  rectal  cases  after  op- 
eration     120 

Organs,  wounds  of  parenchsrma 
of    52 

P 

Packing  the  sterilizer 18 

Pads,  abdominal   23 

Pails  of  agate  ware  for  the  op- 
erating room    30 

Parcels  containing  materials  for 

cleansing    24 

Containing       materials       for 

dressing  _ 24 

Patient's   arrival    from   the   op- 
erating room  . ._ 110 

Care  after  operation 110 

Peritoneal  adhesion    51 

Peritoneum,  healing  of  the....    51 

Peritonitis,  aseptic   51 

Personal  asepsis   _. . .    41 

Physician's  sphere  at  operation.lOl 
Pitcher,  sterile    29 


176 


INDEX 


Page 
Position    of    the    patient    after 

operation,  changes  in  the..  126 
Positive     differential     pressure- 
cabinet,  anesthesia  in 85 

Post-operative   care   of   the   pa- 
tient    110 

Shock,  estimating  the  amount 

of    81 

Treatment,   relations  between 
the    family    physician    and 

surgeon   in    HI 

Duties  of  the  nurse .110 

Use   of  anodynes   and  somni- 
facients, rules  for 112 

Use  of  morphine Ill 

Use  of  dionine 112 

Use   of  codeine  phosphate. .  .118 

Wakefulness,  causes  of 112 

Use  of  veronal 112 

Use  of  veronal-sodium 112 

Use  of  trional 112 

Use  of  tetronal 112 

Use  of  sulphonal 112 

Gastric    upset,     factors    con- 
cerned in   115 

Nausea,  effect  of  lime  water 

oTc  milk  of  magnesia  in 110 

Gas  pain  HI 

Bowel  inertia   Ho 

Use  of  the  enema 123 

Use   of   the   peppermint   ene- 
ma    _ Ill 

Difficulty  in  urination 114 

Catheterization .113 

Record    of    the    quantity    of 

urine   11^ 

Suppression  of  urine .115 

Specimen  of  urine  for  analy- 

Changes  in  position . 126 

Rupture  of  the  suture  line..  128 

Dressing,  the  first.  •••••• }l° 

Dressing  with  silver  leaf 1^9 

Fever  in  aseptic  cases. 133 

Fever,  interpretation  of.....  133 
Bowel  stasis,  influence  on  the 

aseptic  reaction  by ...137 

Fever    curve,     influences    of 

bowel  stasis  on  the ..137 

Fever     curve,     influence     of- 
menstruation  on  the....  ..138 

Fever   curve,    influence   of   a 

slight  skin  infection  on  the.140 
Fever   curve,    influence   of   a 
marked    skin    infection    on 

the  • ..:..140 

Fever  curve,  influence  of  in- 
fluenza nostras  on  the 143 

Diet    115 

Liquid  diet I" 

Convalescent  diet  i-i? 

Full  diet .••;••; i?o 

Use  of  cathartic  food... 119 

Use  of  constipating  food 1^0 

Use  of  opiates  in  rectal  cases.130 

Use  of  mild  cathartics 124 

Use  of  croton  oil 1** 

Use  of  caster  oil i*i 


Page. 

Use  of  calomel. 123 

Use  of  the  evacuative  enema.  123 

Second  week    127 

Posture    of    the    patient    during 
operation,      importance     of 

correct 94 

Of   the    patient   in    drainage, 

importance  of  the 162 

Preface   I 

Preoperative  inanition 116 

Fever  3 

Preparation     of     the     surgeon's 
hands  before  operating. ...   37 
Of  the  patient  for  operation.      5 
Of  the  patient  for  operation, 

nurse's  outline _. . .    12 

Of  the  patient  for  operation, 

general    6 

Of  the  patient  for  operation, 

local ._ 5 

Of  the  patient,  for  an  emer- 
gency operation   10 

Of  the  skin  for  operation. .  .6, 10 
Of  the  mucous  membrane  for 

operation     11 

Preservation  of  catgut  sutures.   70 
Pubic    strip    in    dressing    gyne- 
cological laparotomies    ....  127 
Pulse    before    and    after    anes- 
thesia      80 

Pus    basins    for    the    operating 

room   30 

Pan  for  office  and  dispensary 

use 30 

Avoiding  contact  with. ......   39 

Foci    in    operations,    walling 

off   106 

Evacuation  by  the  expression 

method    164 

Evacuation    by     the     suction 
method    165 


Q 

Qualities  of  suture  material....  60 

R 

Reaction  of  tissues  towards  im- 
bedded catgut   ;•■:••   *1 

Rectal    operations,    constipating 

the  bowel  after 130 

Cases,  use  of  opiates  in 120 

Operations,       emptying      the 

bowel  after 121 

Rectus  incision,  the  mesial ....   95 
Incision,    Indications    for   the 

mesial     97 

Incision,   the    right 98 

Reflex    coughing    during    anes- 
thesia      ; 80 

Reflexes  during  anesthesia,  ab- 
olition  of    77 

Relation  of  the.  deep  epigastric 
artery   to    incisions    in   the 

lower  abdomen 95 

Between  the  surgeon  and  his 
anesthetist    74 


INDEX 


\77 


Page 
Repair  by  wound  healing  is  es- 
sentially  imperfect    47 

Reproductive    power    lost    with 

cell    specialization    45 

Resistance     of     catgut     suture, 
terms    used    to    express    the 

degree   of    63 

Of  catgut  suture  in  the  hu- 
man   tissue    in    relation    to 

the   animal    63 

Responsibility  of  the   surgeon..     1 

Resterilization,   object  of 33 

Effect  on  tetanus  baccilli  pro- 
duced by 33 

Retraction   of  vulnerable  struc- 
tures during  operation. ..  .104 

Rubber  gloves,  sterile 20 

Gloves,  method  of  steriliz- 
ing     ...17,39 

Gloves,  reason  for  wearing. .    36 

Gloves,    objections   to 41 

Tubes  for  wound  drainage.  .159 

Rules  for  safe  operating 4 

For  post-operative  use  _  of 
anodynes  and  somnifa- 
cients     113 

Rupture  of  the  suture  line....  138 

S 

Safe  operating,  rules  for 4 

Safety  of  surgical  measures....     2 

Scalpels,  sterilization  of 34 

Scar  formation,  wound  healing 

and  45 

Formation  _  and  functional 
compensation  are  independ- 
ent  47 

Formation    undesirable    when 

excessive    53 

Tissue,  slight  resistance  of. .   57 
Formation  in  surface  wounds 
and  internal  organs  is  sim- 
ilar      47 

After     operation,     supporting 

the 130 

Scars,  elastic  fibres  in 54 

Does  exercise  encourage  the 
development  of  elastic  fib- 
rils in    58 

Sedative  treatment  of  wounds.  156 
Shock    during    anesthesia,     in- 
duction  of    78 

Following  operation,  estimat- 
ing the_  amount  of 81 

Silk    is    objectionable    for    skin 

suture    _. ._ 68 

Silkworm  gut  for  skin  repair. .   68 

Silver^  leaf,  use  of 129 

Simplified     cleansing     methods 

for  the  skin 7, 10 

Cleansing  methods  to  substi- 
tute disinfection   .  _. 7,10 

Siphonage,   wound  drainage  by 

continuous    _. 163 

Sitting  up  after  operation 131 

Skin  sterilization,  objections  to 
methods  of   5 


Page 

Sterilization      by      combined 

methods  0 

Sterilization    by   a   new   com- 
bined method   7 

Secretion,  relation  of  the  dis- 
infectant to   the 8 

Preparation    for   operation   of 

the    6,10 

Elastic   fibres   in 56 

Suture  is  avoidable 69 

Suture,    objection    to    catgut 

in    68 

Suture,    objection    to    silk   or 

unimpregnated  linen  for...   68 
Suture  with  silkworm  gut...   68 

Clamps    68 

Coaptation  by  means  of  adhe- 
sive  plaster    69 

Infections,  influence  on  post- 
operative reaction  by 140 

Slipperiness  of  the  vaginal  mu- 
cous membrane  lessened  by 

the  use  of  tannic  acid 13 

Of  the  vaginal  mucous  mem- 
brane lessened  by  the  use  of 

zinc  sulphate   13 

Of  the  vaginal  mucous  mem- 
brane lessened  by  the  use 
of  bichloride  of  mercury..   13 
Solution    No.     I     for    prepara- 
tion of  the  skin 7 

No.  II  for  preparation  of  the 

skin 7 

Special  incisions   98 

Specialization    of  cell   and   loss 

of  reproductive  power 45 

Of    cells    does    not    destroy 

their  power  to  grow 46 

Sponges  of  gauze 81 

Tiny    21 

Delta    22 

Spore     forms  _  jn     relation     to 

steam  sterilization   16 

Forms,  boiling  time  necessary 

to  destroy 32 

Stagnating     fluids     as     culture 

media  3 

Fluids    objectionable    at    the 

site  of  an  operation ...107 

Steam    sterilizers,    construction 

of    16 

Sterilization,  steps  in.. 15 

Sterilization    in    relation    to 

bacteria    16 

Sterilization    in    relation    to 

spore  forms   16 

Sterilization,     time     required 

for    16 

Steps  in  the  execution  of  _  the 
semilunar  hypogastric  inci- 
sion      _. . .   87 

In  the  mesial  rectus  incision.  96 
Sterile  wash  and  wound  dress- 
ings  . 14 

Sterility  of  catgut  depends   on 

the  manufacturers   70 

Sterilizable  tops  for  operating 
and  supply  tables 27 


178 


INDEX 


Page 
Sterilization  of  gauze,  by  boil- 
ing       14 

Of    gauze,    by    steam    under 

pressure ,   14 

Comparative     time     required 

for 18 

Repeated   16 

Of  rubber  gloves 17,39 

Of  talcum  powder 19 

Of  utensils   for  operation....  27 
Of  instruments  for  operation.  37 

Of  scalpels 34 

Of    catgut    70 

Of  wounds   155 

Sterilized   gowns    19 

Sterilizer    for    surgical    instru- 
ments         33 

Supply    19 

Stimulant  treatment  of  wounds. 157 
Strips,  skin  coaptation  with  ad- 
hesive     69 

Suction  methods  for  evacuating 

pus    165 

Sulphonal  after  operation 112 

Supply  table    21 

Tables  with  sterilizable  tops.   27 
Surface    sterilization    of   catgut 

tubes    71 

Wounds,  healing  by  granula- 
tion of   52 

Surgeon's   responsibility    11 

Hands,  the 36 

Instruments,     superiority     of 
the     boiling     process      for 

sterilizing  the    31 

Relation   to   his   anesthetist..    74 
Attitude  in  case  oi  vomiting 

during  anesthesia   80 

Duty  towards  the  family  phy- 
sician on  dismissing  a  case.132 

Surgical  judgment    1 

Judgment,  basis  of 167 

Anatomy     of     the     semilunar 

hypogastric  incision    87 

Anatomy  of  the  mesial  rectus 

incision    95 

Case,    relation    of    the    family 
physician    and    surgeon    in 

the  after  care  of  a Ill 

Sutures    contaminated    through 

wet  table  covers 21 

Suture  tray   21 

Material,  aseptic  59 

Sutures   are   foreign  bodies 59 

Are  avoidable  in  the  skin.  ...   59 

Object    of    59 

Absorbable    60 

Suture  material,  requisite  qual- 
ities of   60 

Suture    of    catgut    microscopic     • 
changes  during  the  absorp- 
tion of   61 

Sutures     of     catgut,     moisture 

starts  the  dissolution  of . . .   61 
Suture  resistance  to  absorption, 
terms  used  to  indicate 62 


Page 

Of  catgut  in  the  human  sub- 
ject, terms  indicating  re- 
sistance are  of  relative  sig- 
nificance  in    63 

Of   catgut,   actual   period   of- 

usefulness   of 63 

Sutures  of  catgut,  water  is  es- 
sential for  the  action  of 
cell   enzymes   on 64 

Highly  chromicized  are  pref- 
erable to  bulky 65 

Fine    chromicized     catgut    to 

replace   in   absorbable 65 

Suture  resistance  of  "40"  and 
"60    day"    most    generally 

useful    66 

Sutures    of    catgut    should    be 

aseptic  not  antiseptic 66 

Indications  for  using  absorb- 
able and  inabsorbable 67 

Of  linen  for  hollow  organs..  68 
Sutures    of   the    skin,   objection 
to  catgut  in 68 

Of  silk  or  _  unimpregnated 
linen  objectionable  for  skin' 
union    68 

Of  skin  with  silkworm  gut. .   68 

Of  catgut  in  sealed  tubes, 
effect  of  boiling  on 71 

Line,  rupture  of  the 128 

Sweat,  the  fatty  nature  of 9 

T 

Table  of  contents V 

For  supplies 21 

For   instruments    31 

The   Hartley    23 

I,  mean  daily  rectal  tempera- 
ture  preoperative    144 

II,  daily  mean  temperature 
in  aseptic  laparotomies, 
rectal  and  oral  tempera- 
tures compared 145 

III,  rectal  and  oral  tempera- 
tures in  the  same  patient 
taken  simultaneously  near 
the  end  of  the  first  week 
after  hysterectomy  _. 145 

IV,  the  maximum  rise  and 
the  time  of  its  occurrence, 
rectal   temperatures    145 

V,  mean  daily  rectal  tempera- 
ture, second  week  post-op- 
erative     146 

Talcum  powder,  sterilization  of.  19 

Tampons  of  gauze 23 

Tannic  acid  for  vaginal  douche.  13 

Technic,  dexterous 1 

Of  the  semilunar  hypogas- 
tric incision   87 

Of  the  mesial  rectus  incision.  95 
Of  anesthesia  in  operation  on 

the  brain    _ 83 

Of  anesthesia  in  operation  on 

the   larynx    84 

Temperature,  normal  rectal, 

133,  136 


INDEX 


179 


Page 

Temperature,  normal  oral 131 

Relation  between  oral  and 
rectal   134 

Registered  most  accurately  in 
the  proximity  of  the  le- 
sion     134 

Reaction  after  clean  opera- 
tions  134 

After  operations,  time  of  oc- 
currence  of   the   maximum 

rise  in  the 135 

After  operation,  amplitude  of 

the  maximum  rise  in  the..  135 
Influence  of  the  time  of  day 

on  postoperative   135 

After  operation,  relation  of 
the     post-maximal     to     the 

maximum  rise  in  the 135 

After  operation,  the  promaxi- 
mal  in  relation  to  the  maxi- 
mum rise  in  the 135 

After  operation,  influence  of 

menstruation   on  the 138 

After     operation,     effect     of 

bowel  stasis  on  the 137 

After     operation,     effect     of 

slight  infections  on  the...  140 
After      operation,     effect     of 
marked   skin    infections   on 

the    ...140 

After  operation,  effect  of  in- 
fluenza nostras  on  the 143 

Tension,  drainage  by  chemical.. 161 
Terms   used   to   indicate   catgut 

resistance     63 

Tetanus   bacillus,   resistance  of 

the    33 

Bacillus,  effect  of  drying  on 

the 33 

Tetrachloride   of   carbon 8 

Tetronal    after    operation 112 

Theory    of    the    significance    of 

elastic   fibres    54 

Concerning  the  interpretation 
of  post-operative  fever....  144 
Thermic  methods  for  sterilizing 

dressings    14 

Thread  of  linen  for  hollow  or- 
gans    ■  •   68 

Thrombophletitis    with    afebrile 

intervals    ;  •  •     3 

Time    required    for    sterilizing 
instruments   or  utensils  by 

boiling     ••   32 

Required  for  rendering  the 
hands   surgically  clean....   37 

Tiny  sponges V  '  • '  V,'  V   ^^ 

Tissue  reaction  towards  imbed- 
ded catgut    ;■•••;  "-^ 

Water  essential  for  action  oi 

cell  enzymes  on  catgut 64 

Towels,  sterile 20 

Disposal   of   soiled i^ 

Tray  for  sutures V  ' •, c7 

Treatment  of  unclean  wounds..l54 

Of  wounds,  sedative loo 

Of  wounds,  stimulant lo? 

Trional   after   operation 11» 


Page 

Tuberculosis   in   its   relation   to 

anesthesia    82 

Tube    used    during    anesthesia, 

the  breathing 80 

Narcosis  in  operating  on   the 

brain     83 

Narcosis,  intratracheal,  in  tu- 
mors of  the  larynx 84 

Tubes  of  catgut,  boiling  the...    71 
Of  rubber   for  wound  drain- 
age   159 

Tunore  of  the  larynx,  narcosis 
in    84 

U 
Unclean       wounds,       treatment 
of    154 

Urination,    post-operative    diffi- 
culty in 113 

Urine    after    operation,    record- 
ing the  quantity  of.. 114 

Post-operative  suppression  of.ll5 

Analysis  after  operation 114 

Utensil    sterilizer    27 

Sterilizer,      articles      to      be 

boiled  in  the 28 

Utensils      for    _  the      operating 

room,  classified   28 

For  the  operating  room,  ster- 
ilization by  boiling  the....   27 
For  the  operating  room,  time 
required    for   sterilizing   by 

boiling  the    _ 32 

And     instruments,     steriliza- 
tion  of    27 


V 

Vegetarianism,  the  question  of.l25 
Venous    blood    during    anesthe- 
sia, the   significance  of....  80 

Veronal  after  operation 112 

Veronal-sodium   after   operationll2 
Vomiting   during   anesthesia...   80 
Volnerable     structures,     retrac- 
tion of   104 

W 

Wash     and     wound     dressings, 

sterile    14 

Water   is   essential   for   the   ac- 
tion   of    cell    enzymes    on 

catgut    64 

Weir's     extension     of     McBur- 

ney's    incision    98 

Wet  covers  as  sources  of  dan- 
ger from  infection 21 

Wound    contamination,    sources 

of 40 

Dressing,   sterile    14 

Dressing  in  clean  cases 130 

Disinfection     155 

Doubtful   154 

Dressing,  final   130 

Wounds,  industrial  154 


180 


INDEX 


Page 
Wound     dressing     with     silver 

^  leaf    129 

Support  after  operation 130 

Wounds,    three    stages    in    the 

healing  of  unclean 155 

The  stage  of  infection  in  sec- 
ondary healing  of .....156 

Stage   of   expurgation   in   the 

healing    of    unclean 158 

The  stage  of  aseptic  healing 

of  unclean    166 

Wound  sterilization   155 

Wounds,  treatment  of  unclean.154 

Sedative  treatment  of 156 

Stimulant  treatment  of 157 

Appearance    of    elastic    fibres 

in  healing 54 

Wound  discharge    158 

Wounds,   drainage  of  discharg- 
ing     159 

Drainage,  devices  for  aiding.159 
Drainage    by    means    of    rub- 
ber  tubes    159 

Drainage  of  a  small 159 

Wounds,  metal  drains  for 160 

Wound  drainage,  factors  in...  161 


Page 

Drainage    by    chemical    ten- 
sion     161 

Drainage  by  gravitation 162 

Drainage    by    continuous    si- 

phonage   163 

Healing  and  scar  formation..  45 
Healing    is    an    imperfect    re- 
pair         47 

Healing,    role    of    connective 

tissue   in    47 

Healing,  minor  role  of  other 

besides  connective  tissue  in  48 
Healing,  constitutional  causes 

of  slow    157 

Healing,  local  causes  of  slow. 157 

Wounds  of  bone 49 

Of  cartilage 48 

Of  smooth   muscle 50 

Of  striated  muscle 49 

Of  heart  muscle 50 

Of    nerve    tissue 51 

Of  the  parenchyma  of  secret- 
ing organs    53 

Involving  the  peritoneum. ...    51 
Of    the    surface,    granulation 
of    53 


NW 


on  oo^.^'^ii^iy^.^SITY  LIBRARIES  (hsi.stx) 
nU  00  Ncy  C.I 

Guidina  iRIinciples  in  suraical  practice. 

2002108224 


